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      Calc Function

    • Calcs that help predict probability of a diseaseDiagnosis
    • Subcategory of 'Diagnosis' designed to be very sensitiveRule Out
    • Disease is diagnosed: prognosticate to guide treatmentPrognosis
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    Patent Pending

    History and Electrocardiogram-only Manchester Acute Coronary Syndromes (HE-MACS)

    Stratifies ACS risk with history and EKG only (not yet externally validated).
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    INSTRUCTIONS

    Use in patients ≥18 years old presenting with suspected cardiac chest pain (symptoms within the last 24 hours).

    When to Use
    Pearls/Pitfalls
    Why Use

    Patients ≥18 years old presenting with suspected cardiac chest pain (symptoms within the last 24 hours).

    • 30-day major adverse cardiac event (MACE) was defined as acute MI, all-cause death, or coronary revascularization.

    • Not yet prospectively validated (externally validated in a single cohort retrospectively; see Evidence for details).

    • Validated in emergency settings and not yet validated in paramedic, primary care, or triage-specific settings.

    Point to keep in mind:

    • Note that the authors chose the cutoff for ACS probability in the “very low risk” group (<4%) as determined by receiver operator curve (ROC) analysis to achieve 100% sensitivity (i.e., to miss no cases of ACS or 30-day MACE), not necessarily as a reasonable clinical risk threshold for rule-out.

    • May be a useful adjunct to clinical judgment, especially in resource-limited settings where biomarkers are not available.

    • Accurate risk stratification of patients prior to biomarker information may enhance triage and help guide disposition.

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    Result:

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    Next Steps
    Evidence
    Creator Insights

    Advice

    • In patients who are “very low” risk, ACS is unlikely. Consider discharge without cardiac biomarkers, with caution, and consider further investigation in an ambulatory setting.

    • “Very low” risk was <4.0% risk of ACS or MACE in 30 days, which was selected by the authors to achieve 100% sensitivity in the derivation cohort, and was subsequently found to be 99.5% sensitive (95% CI 97.1-100) in validation cohorts.

    • In patients who are not “very low” risk, further workup is recommended.

    Critical Actions

    • HE-MACS is a decision aid and not a definitive test that is designed to assist in the risk stratification of patients with chest pain. Clinical judgment should always be used.

    • Where all the HE-MACS decision aid components are negative and a “very low” risk of ACS or 30-day MACE is identified, ACS is unlikely and discharge without cardiac biomarkers may be considered, with caution.

    Content Contributors
    • Govind Oliver, MD
    About the Creator
    Abdulrhman Alghamdi
    Dr. Richard Body
    Are you Dr. Richard Body?
    Content Contributors
    • Govind Oliver, MD