Comparison of four decision aids for the early diagnosis of acute coronary syndromes in the emergency department

Emerg Med J. 2020 Jan;37(1):8-13. doi: 10.1136/emermed-2019-208898. Epub 2019 Nov 25.


Objectives: To directly compare the diagnostic accuracy of four decision aids (Troponin-only Manchester Acute Coronary Syndromes (T-MACS), History, ECG, Age, Risk factors and Troponin (HEART), Thrombolysis in Myocardial Infarction (TIMI) and Emergency Department Assessment of Chest Pain (EDACS)) used to expedite the early diagnosis of acute coronary syndromes (ACS) in the ED.

Methods: We prospectively included patients who presented to 14 EDs in England (February 2015 to June 2017) with suspected ACS within 12 hours of symptom onset. Data to enable evaluation of the T-MACS, HEART, TIMI and EDACS decision aids (without recalibration) were prospectively collected, blinded to patient outcome. We tested admission blood samples for high-sensitivity cardiac troponin I (hs-cTnI; Siemens ADVIA Centaur). Patients also underwent serial cardiac troponin testing over 3-12 hours. The target condition was an adjudicated diagnosis of acute myocardial infarction (AMI). We also evaluated the incidence of major adverse cardiac events (including death, AMI or coronary revascularisation) at 30 days. Diagnostic accuracy of each decision aid and hs-cTnI alone (using the limit of quantification cut-off, 3 ng/L) was evaluated by calculating sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV).

Results: Of 999 included patients, 132 (13.2%) had AMI. C-statistics were 0.96 for T-MACS, 0.78 for HEART and 0.69 for TIMI. The sensitivities of T-MACS, HEART, TIMI, EDACS and hs-cTnI <3 ng/L for AMI were 99.2% (95% CI 95.7% to 100.0%), 91.8% (85.0% to 96.2%), 97.5% (92.9% to 99.5%), 96.2% (92.2% to 99.4%) and 99.2% (95.9% to 100.0%), respectively. The respective strategies would have ruled out 46.5%, 34.9%, 19.4%, 48.3% and 28.8% patients. PPVs for the decision aids that identify 'high-risk' patients were 80.4% (T-MACS), 51.9% (TIMI) and 37.2% (HEART).

Conclusions: In this study, T-MACS could rule out AMI in 46.5% patients with 99.2% sensitivity. EDACS could rule out AMI in 48.3% patients with lower sensitivity, although the difference was not statistically significant. The HEART and TIMI scores had lower diagnostic accuracy.

Keywords: acute coronary syndrome; cardiac care, diagnosis; diagnosis.

Publication types

  • Comparative Study
  • Multicenter Study

MeSH terms

  • Acute Coronary Syndrome / blood
  • Acute Coronary Syndrome / diagnosis*
  • Acute Coronary Syndrome / mortality
  • Aged
  • Biomarkers / blood
  • Chest Pain / blood
  • Chest Pain / diagnosis*
  • Chest Pain / mortality
  • Decision Support Techniques
  • Early Diagnosis
  • Electrocardiography
  • Emergency Service, Hospital*
  • England / epidemiology
  • Female
  • Humans
  • Male
  • Middle Aged
  • Practice Guidelines as Topic
  • Predictive Value of Tests
  • Prospective Studies
  • Risk Assessment
  • Sensitivity and Specificity
  • Troponin I / blood*
  • Troponin T / blood*


  • Biomarkers
  • Troponin I
  • Troponin T