Troponin-only Manchester Acute Coronary Syndromes (T-MACS) Decision Aid

T-MACS Decision Aid

Ischemia on ECG (ST-segment or T-wave changes)

Worsening or crescendo angina

Pain radiating to arm or shoulder

Pain associated with vomiting

Observed sweating (diaphoresis)

Hypotension (SBP <100 mmHg)

Troponin elevated above 99th percentile

Score:–

–

Rules out acute coronary syndrome.

Why Use

Can essentially rule OUT ACS in very low risk patients. Can essentially rule IN ACS in high risk patients. Can avoid costly hospital admissions or risk of harm from invasive tests in patients predicted not to have ACS or risk of 30-day MACE.

When to Use

Patients with chest pain that may be cardiac in nature.

Formula

Probability of ACS (p) = where: No Yes E: EKG ischemia 0 1 A: Worsening or crescendo angina 0 1 R: Pain radiation to the right arm or shoulder 0 1 V: Pain associated with vomiting 0 1 S: Sweating observed 0 1 H: Hypotension 0 1 T: hs-cTnT concentration on arrival hs-cTnT value Remember, hs-cTnT has low specificity—troponin may be elevated by a number of non-ACS etiologies, including: Cardiac causes Cardiac contusion (trauma) Heart failure, acute and chronic Tachy- or bradyarrhythmia, heart block Cardiac surgery Aortic dissection Apical ballooning syndrome Cardioversion Aortic valve disease Post-PCI Endomyocardial biopsy Hypertrophic cardiomyopathy Rhabdomyolysis with myocyte necrosis Myocarditis Endocarditis Pericarditis Non-cardiac causes PE Severe pulmonary HTN Renal failure Stroke, SAH Amyloidosis, other infiltrative diseases Cardiotoxic drugs Critical illness Sepsis Extensive burns Extreme exertion From Mahajan 2011 .

Pearls / Pitfalls

The T-MACS Decision Aid predicts acute coronary syndrome (ACS) or 30-day major adverse cardiac events (MACE) in patients with suspected cardiac chest pain. 30-day MACE was defined as acute myocardial infarction (AMI), death, or coronary revascularization. Uses high sensitivity cardiac troponin T (hs-cTnT), along with subjective symptoms and objective signs to risk stratify chest pain patients with suspected cardiac chest pain. Uses a single hs-cTnT measurement on arrival, not serial values like other chest pain scores. Inclusion and exclusion criteria differed slightly between the derivation and validation sets, e.g. chest pain within 12 vs. 24 hours of onset; age limits 16 vs. 18 vs. 25 years old. Point to Keep in Mind: Remember, hs-cTNT is also a low-specificity troponin. While it may suggest ACS in high-risk patients, it can be elevated for many other reasons besides acute coronary syndromes. See Evidence for differential diagnoses.

Critical Actions

T-MACS is a decision aid and not a definitive test. It is designed to assist in the workup of a patient’s chest pain. Clinical judgment should always be used. If all the components of the T-MACS decision aid are negative, ACS can essentially be ruled out without having to calculate the score.

More Information

Interpretation: Probability Risk Interpretation <0.02 Very low ACS ruled out. Consider discharge. ≥0.02 and <0.05 Low Consider serial troponin in ED ward, e.g. 3h troponin; consider discharge if normal. ≥0.05 and <0.95 Moderate Serial troponin in general ward and consider stress testing and/or CT coronary angiography thereafter. ≥0.95 High ACS ruled in. Refer to cardiology, treat for ACS.