Feasibility of the Manchester Acute Coronary Syndromes (MACS) decision rule to safely reduce unnecessary hospital admissions: a pilot randomised controlled trial

Body, R., Boachie, C., McConnachie, A. , Carley, S., Van Den Berg, P. and Lecky, F. E. (2017) Feasibility of the Manchester Acute Coronary Syndromes (MACS) decision rule to safely reduce unnecessary hospital admissions: a pilot randomised controlled trial. Emergency Medicine Journal, 34(9), pp. 586-592. (doi: 10.1136/emermed-2016-206148) (PMID:28500087) (PMCID:PMC5574380)

Abstract

Background Observational studies suggest that the Manchester Acute Coronary Syndromes (MACS) decision rule can effectively ‘rule out’ and ‘rule in’ acute coronary syndromes (ACS) following a single blood test. In a pilot randomised controlled trial, we aimed to determine whether a large trial is feasible. Methods Patients presenting to two EDs with suspected cardiac chest pain were randomised to receive care guided by the MACS decision rule (intervention group) or standard care (controls). The primary efficacy outcome was a successful discharge from the ED, defined as a decision to discharge within 4 hours of arrival providing that the patient did not have a missed acute myocardial infarction (AMI) or develop a major adverse cardiac event (MACE: death, AMI or coronary revascularisation) within 30 days. Feasibility outcomes included recruitment and attrition rates. Results In total, 138 patients were included between October 2013 and October 2014, of whom 131 (95%) were randomised (66 to intervention and 65 controls). Nine (7%) patients had prevalent AMI and six (5%) had incident MACE within 30 days. All 131 patients completed 30-day follow-up and were included in the final analysis with no missing data for the primary analyses. Compared with standard care, a significantly greater proportion of patients whose care was guided by the MACS rule were successfully discharged within 4 hours (26% vs 8%, adjusted OR 5.45, 95% CI 1.73 to 17.11, p=0.004). No patients in either group who were discharged within 4 hours had a diagnosis of AMI or incident MACE within 30 days (0.0%, 95% CI 0% to 20.0% in the intervention group). Conclusions In this pilot trial, use of the MACS rule led to a significant increase in safe discharges from the ED but a larger, fully powered trial remains necessary. Our findings seem to support the feasibility of that trial. Trial registration number ISRCTN 86818215. Research Ethics Committee reference: 13/NW/0081. UKCRN registration ID:14334.

• Item Type: Articles
• Additional Information: This trial was funded by the National Institute for Health Research via a postdoctoral fellowship grant (reference PDF-2012-05-193) awarded to Richard Body.
• Keywords: Acute coronary syndromes, acute myocardial infarction, clinical decision rules, diagnosis, emergency medicine, sensitivity and specificity, troponins, high sensitivity.
• Status: Published
• Refereed: Yes
• Glasgow Author(s) Enlighten ID: McConnachie, Professor Alex and Boachie, Mr Charles
• Authors: Body, R., Boachie, C., McConnachie, A., Carley, S., Van Den Berg, P., and Lecky, F. E.
• College/School: College of Medical Veterinary and Life Sciences > School of Cardiovascular & Metabolic Health; College of Medical Veterinary and Life Sciences > School of Health & Wellbeing > Robertson Centre
• Journal Name: Emergency Medicine Journal
• Publisher: BMJ Publishing Group
• ISSN: 1472-0205
• ISSN (Online): 1472-0213
• Published Online: 12 May 2017
• Copyright Holders: Copyright © 2017 The Authors
• First Published: First published in Emergency Medicine Journal 34(9): 586-592
• Publisher Policy: Reproduced under a Creative Commons License