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

What is it about?

Chest pain is a very common and often a very frightening symptom, which may be caused by a heart attack but is more often caused by much less serious conditions such as indigestion or muscle pain. Unfortunately it is often impossible to tell what has caused the symptoms without doing tests. Therefore, if a doctor in the Emergency Department suspects that a patient's symptoms could have been caused by a heart attack, then the patient will usually undergo at least two blood tests over several hours. Only around 1 in 10 patients who have tests have actually had a heart attack. We therefore need better tests, which can be used when patients first arrive in the Emergency Department, so that patients can receive early reassurance when they are healthy and to reduce the increasing problem of hospital crowding.

Blood tests for a protein called troponin, which is contained in heart muscle, can now quickly help doctors to be confident that some patients do not have a heart attack. However, we may be able to make more accurate diagnoses if we don't just take account of blood test results, but if we also take into account important details of a patient's symptoms, previous history and the heart tracing (ECG). Decision aids help doctors to combine all of this information in a structured way to make quick, accurate diagnoses in the Emergency Department.

In this work we compared the accuracy of four of these decision aids. The decision aids are called 'T-MACS', the 'HEART score', the 'EDACS score' and the 'TIMI score'. We found that T-MACS and EDACS could reassure the most patients after a single blood test. T-MACS appeared to be the most accurate score, as it would miss fewer diagnoses of heart attack, while it was also the most efficient decision aid for spotting high risk patients who are very likely to have a diagnosis of heart attack. 

Our findings will help clinicians working in Emergency Medicine to decide which decision aids to use when caring for patients attending the Emergency Department with chest pain.

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