ACS Championship Preview

January 13, 2020

Written by Thomas Davis

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T-MACS and EDACS outperformed HEART and TIMI in a head-to-head comparison of decision aids used to rule out acute coronary syndrome.  

Why does this matter?
The literature is cluttered with different decision aids: HEART, TIMI, GRACE, EDACS, and T-MACS.  In the United States, the HEART score has been almost universally adopted by emergency physicians and has received the most first-place votes in the EP poll.  This study finally lets the top 4 scoring systems to go head-to-head in the 2020 ACS Playoffs. However, just like in the college football BCS Championship era, one team always gets left out of the finals—sorry GRACE. 

The winning score in tonight’s ACS Championship is…
This was a nested study that prospectively collected data from 999 patients who presented to one of 14 emergency departments in England with symptoms concerning for ACS.  The study used a single troponin test (hs-cTnI, Siemens ADVIA Centaur) on initial ED presentation to evaluate an early rule-out strategy.  The authors compared four decision aids to a blinded and adjudicated diagnosis of type I AMI.  The reference standard was serial troponin measurement as prescribed by the third universal definition of myocardial infarction. 13.2% of patients had AMI.  T-MACS had the highest sensitivity and NPV (99.2% and 99.8%, respectively) although it was not statistically different from EDACS (sensitivity 96.2% , NPV 99.3%).  Both T-MACS and EDACS identified the highest percentage of patients for early discharge (46% and 48%, respectively).  The HEART score performed the worst in terms of sensitivity (91.8%) which was statistically significant compared to T-MACS (p=0.004).  Furthermore, the HEART score only identified 35% of patients for early discharge.  Be aware that this study was led by Rick Body, the super smart creator of T-MACS, so there is some risk of bias. Nonetheless, given prior literature comparing the HEART score to EDACS, my vote is for the HEART score to lose its #1 seed.

Source
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.

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