Cardiology

T-MACS score vs HEART score identification of major adverse cardiac events in the emergency department

a b s t r a c t

Background: Ischemic heart disease is the leading cause of mortality worldwide, and its prevalence is rising. Objective: The goal of this study was to evaluate the HEART and T-MACS scores for predicting major cardiac events (MACE) in patients presenting to the emergency department with chest pain.

Method: This study was single center and prospectively conducted. The demographic information, T-MACS and HEART scores of the participants were recorded and calculated. Acute myocardial infarction (AMI), mortality, and the need for coronary revascularization were considered as Major adverse cardiac events (MACEs). The statistical analysis was carried out using SPSS (IBM Statistics, New York) version 24, and significance was determined at the p < 0.05 level.

Results: The 514 patients included in our study had a mean age of 52.01 +- 19.10 years, with 55.3% were female and 44.7% was male. A total of 78(%15.1) cases were diagnosed with AMI. Fifty patients (%9.7) underwent percu- taneous coronary intervention, 12 (%2.3) patients underwent coronary artery by-pass graft, and 8 (%1.5) patients died within a one-month period. The sensitivity and negative predictive values of the T-MACS score for the Very low risk classification were 93.90% (86.3%-98.0%) and 97.7% (94.7%-99.0%), respectively, and the sensitivity and negative predictive values of the HEART score for the low risk classification were 89.59% (77.3%-93.1%) and 96.6% (94.2%-98.0%), respectively. The specificity and positive predictive values for the high risk classification were 99.77% (98.7%-100%) and 97.2% (82.9%-99.6%), respectively for the T-MACS score and 95.14% (92.7%-97%) and 63.2% (51.4%-73.5%), respectively for the HEART score.

Conclusion: The T-MACS score was shown to be more accurate than the HEART score in predicting low risk (very low risk for the T-MACS score), high risk, and anticipated one-month risk for MACE in patients coming to the emergency department with chest pain.

(C) 2022

  1. Introduction

Worldwide, ischemic heart disease is the leading cause of death, and its incidence is increasing. While there are significant disparities across nations, ischemic heart disease claims 1.8 million lives each year and has a mortality rate of 20% [1,2]. While the incidence of ST-segment el- evation myocardial infarction (STEMI) continues to decline, the inci- dence of non-ST segment elevation myocardial infarction (NSTEMI) continues to rise [3,4]. Early identification and treatment beginning

* Corresponding author.

E-mail address: [email protected] (N.M. Hokenek).

have a beneficial influence on mortality in individuals with acute coro- nary syndrome (ACS).

The development of High-sensitivity troponin has facilitated the dif- ferential diagnosis of acute myocardial infarction (AMI) tremendously. Periodic increases in troponin levels allow clinicians to diagnose AMI. Waiting for the troponin test to make a diagnosis in the emergency ser- vices has become exceedingly expensive, as it wastes time and leads to unnecessary hospitalizations. Utilizing patients’ troponin values, medi- cal histories, physical examination findings, and ECGs, numerous grad- ing systems have been developed. Troponin-only Manchester Acute Coronary Syndromes (T-MACS) and History, ECG, Age, Risk factors, and troponin (HEART) are the most frequently used scoring systems.

https://doi.org/10.1016/j.ajem.2022.11.015

0735-6757/(C) 2022

As a result, early detection and treatment of patients have become critical for minimizing mortality associated with ischemic heart disease. STEMI may be identified by a single or serial electrocardiogram (ECG) in patients who report with chest discomfort, however NSTEMI may be more difficult to identify. To address this worldwide issue, new recom- mendations propose the use of Risk scoring systems such as T-MACS, and HEART when evaluating chest discomfort [5-9].

The goal of this study was to evaluate the HEART and T-MACS scores for predicting major cardiac events (MACE) in patients presenting to the emergency department with chest pain.

  1. Methods
    1. Study design and setting

This study was planned as a prospective observational study in the tertiary care emergency department for a 1-year period between 01/ 11/2018-01/11/2019. Ethical committee approval obtained (Number: HNEAH-KAEK 2018/79) Written informed consent form taken from all the patients included.

    1. Participants

Patients over the age of 18 who presented with chest pain were eval- uated for past medical history, probable causes, and other symptoms. Additionally, the patients received a physical examination and ECG, as well as blood samples for the troponin test. Ten patients excluded under the age of 18, those with ST-segment elevation, pneumonia, pneumothorax, aortic pathologies, pulmonary thromboembolism, renal failure, or pregnancy, those with gastrointestinal tract disorders and unable to provide written informed consent. Also 15 patients who require hospital admission due to another medical condition (to ex- clude patients with type 2 AMI) excluded. As a consequence, the sample comprised 514 patients that met the required criteria.

    1. Data collection

The data collected prospectively by the primary clinicans with a standard bespoke form. An electronic form was also created in the hos- pital automation system before the study started. The data sheets were transferred to the electronic form by a blinded secretary. The medical histories of the patients were scanned from the national health system and the previous Internatinol Classification of Diseases (ICD) 9th edition Diagnosis codes were added to the data forms. These forms were exam- ined by another physician, and missing or incorrect records were re- viewed. Risk scores were generated based on the individuals’ risk modalities. At admission, a troponin test was performed on all patients. The 3rd and 6th hour Troponin tests were observed in the admissions of all patients, with the exception of those diagnosed with ST elevation acute coronary syndrome and sent for emergent invasive intervention. Since 1-month mortality was assessed in the trial, participants were monitored for 1 month. The National Death Notification System was also used to get information on the existence of death within one month of inclusion in the trial. Patients were contacted upon discharge using the contact information they supplied to the study.

    1. Variables

We documented demographic information (age, sex), past medical history (hypertension, hyperlipidemia, diabetes mellitus, obesity), fam- ily history of acute myocardial infarction before the age of 65 years, absence/presence of smoking, vital signs (blood pressure, pulse, respira- tory rate, fever), pain site (chest, arm, neck, shoulder), absence or pres- ence of vomiting and diaphoresis, electrocardiography findings. The responsible physician reviewed the occurrence of an ACS diagnosis, the presence or absence of increasing chest pain, and ECG abnormalities.

The following parameters were considered when calculating the T-MACS score: a) acute ischemic change in the electrocardiogram (ECG), b) angina with a worsening (or increasing) pattern, c) pain radiat- ing to the right shoulder or right arm, d) vomiting associated with pain,

e) diaphoresis observed in the emergency department, f) hypotension (systolic blood pressure 100 mmHg), and g) high-troponin levels. All pa- rameters except ‘g’ were assigned a value of ‘1’ if they were present and a value of ‘0’ if they were not. To calculate the ‘g’ parameter, the troponin level was fed into the T-MACS calculator. At this stage, a computer, tablet or mobile phone was used to calculate the T-MACS score [10].

The cases were classified as ‘very low risk’ (to rule out ACS), ‘low risk’ (serial hs-trop testing is appropriate in the observation area of the emergency department or outpatient care unit),’moderate risk’ (suit- able for serial hs-trop testing in the observation area of the emergency department), or ‘high risk’ (to rule in ACS) [10,11]. The HEART score is an acronym for five clinical decision-making parameters: history, elec- trocardiogram, age, risk factors, and troponin value. Each of these criteria is assigned a value between 0 and 2, and the overall score is be- tween 0 and 10 [12]. The HEART score was determined as follows in this study: history (2 points for high probability of suspicion, 1 point for moderate probability, and 0 point for low probability); ECG findings (2 points for significant ST depression, 1 point for non-specific ECG changes, and 0 point for normal ECG findings); age (2 points for 65 years and older, 1 point for 45-65 years, and 0 point for 45 years and under); risk factors (family history of acute myocardial infarction before the age of 65 years, smoking, hypertension, hyperlipidemia, diabetes mellitus, and obesity (b) [13,14]. In low-risk patients (0-3 points), ACS was ruled out and early discharge was recommended; in moderate-risk patients (4-6 points), serial hs-trop testing was performed in the emergency department observation area; and in high-risk patients with a pre-diagnosis of ACS, follow-up in the Coronary intensive care unit was initiated [13,14].

    1. Statistical analysis

IBM SPSS Statistics v. 24 (IBM SPSS, New York) software and MedCalc 12.3.0.0 for Windows (MedCalc Software, Mariakerke, Belgium) were used to conduct statistical analysis on the study’s results. The Shapiro-Wilk test was used to determine the parameters’ confor- mance to the normal distribution. Along with descriptive statistics (mean, standard deviation, and frequency), qualitative data were com- pared using the chi-square, Fisher’s exact, and Fisher-Freeman-Halton tests. The McNemar test and the kappa coefficient were used to deter- mine the concordance of the HEART and T-MACS scores in qualitative data. Also, for comparison of HEART and TMAC scores in predicting the presence of MACE, DeLong. et al. analysis was used. The significance value was taken as p < 0.05.

  1. Results

The sample comprised of 284 (55.3%) females and 230 (44.7%) males. The study’s patients varied in age from 18 to 94 years, with a mean of 52.01 +- 19.10 years. The distribution of study parameters is shown in Table 1.

Major adverse cardiac events (MACEs) were diagnosed in 82 partic- ipants. In total, 78 patients were diagnosed with acute myocardial in- farction (AMI). There was no statistically significant difference in gender between the 34 female (43.5%) and 44 male (56.4%) AMI pa- tients (p > 0.05). Mortality was observed in eight cases. MACE was shown to be statistically considerably more prevalent in males (19.6%) than in women (13%) (p > 0.05). There was, however, no statistically significant difference in the one-month death rate between men and women (p > 0.05).

According to the HEART score categorization, 3.1% (n = 10) of low- risk patients, 23.9% (n = 33) of moderate-risk patients, and 61.4% (n = 35) of high-risk patients experienced AMI, with a statistically significant

Table 1

Distribution of study parameters.

Min-Max

Mean +- SD

Age

Gender

Female

18-94

n

284

52.01 +- 19.09

%

55.3

Male

230

44.7

HEART score risk

Low risk

319

62.1

classification (n = 514)

T-MACS score risk

classification (n = 514)

Low risk

88

17.2

Moderate risk

173

33.5

High risk

36

7

Acute myocardial infarction

Absent

436

84.8

Present

78

15.2

One-month mortality status

Non-mortality

506

98.4

Mortality

8

1.6

MACE

Absent

432

84.0

Present

82

16.0

Moderate risk 138 26.8

High risk 57 11.1

Very low risk 217 42.3

(33%-55%), 95.14% (92.7%-97%), 63.2% (51.4%-73.5%), and 89.9%

(88.1%-91.5%), respectively for the high-risk classification.

The sensitivity, specificity, positive predictive and negative predictive values of the T-MACS score were determined as 93.90% (86.3%-98.0%), 49.19% (44.4%-54.0%), 26% (24%-28.1%), and 97.7%

(94.7%-99.0%), respectively for the very low risk classification, and 42.68% (31.8%-54.1%), 99.7% (98.7%-100%), 97.2% (82.9%-99.6%), and

90.1% (88.4%-91.7%), respectively for the high-risk classification. The ROC curve of one month MACE prediction for both scoring systems has been shown in Figs. 1 and 2.

  1. Discussion

The T-MACS score was shown to be more effective than the HEART score in identifying high-risk and very low-risk patients presenting to the emergency room with chest discomfort. Body et al. observed that when four scoring systems were compared in 999 patients, the T-MACS score was shown to be superior to the HEART score in terms of both specificity and sensitivity [15]. Additionally, Hreko et al. re-

SD, standard deviation; MACE, major adverse cardiac event.

difference between risk categories (p < 0.05). Additionally, death oc- curred in 0.3% (1 patient) of low-risk patients, 2.9% (4 patients) of moderate-risk patients, and 5.3% (3 patients) of high-risk patients, dem- onstrating a statistically significant difference (p < 0.05). Finally, MACE was found at a rate of 3.4% (n = 11) in the low-risk group, 25.4% (n = 35) in the moderate-risk group, and 63.2% (n = 36) in the high-risk group, with a statistically significant difference (p < 0.05) in the moderate-risk group (Table 2).

For the T-MACS risk categorization, AMI was present in 2.3% (n = 5) of very low-risk patients, 5.7% (n = 5) of low-risk patients, 19.8% (n = 34) of moderate-risk patients, and 94.4% (n = 34) of high-risk pa- tients, with a statistically significant difference between these groups (p

< 0.001). None of the very low-risk patients died, but death occurred in 1.1% (n = 1) of low-risk patients, 2.9% (n = 5) of moderate-risk pa- tients, and 5.6% (n = 1) of high-risk patients, demonstrating a statisti- cally significant difference (p < 0.05). The extremely low-risk group had a considerably lower Death rate than the moderate-risk and high- risk groups (p < 0.05). No statistically significant variations in mortality rates were seen among the remaining risk groups (p > 0.05). MACE was detected at a rate of 2.3% (n = 5) in the very low-risk group, 6.8% (n = 6) in the low-risk group, 20.9% (n = 36) in the moderate-risk group, and 97.2% (n = 35) in the high-risk group, indicating a statistically signifi- cant difference (p < 0.05) in the low-risk group (Table 3).

The sensitivity, specificity, positive predictive and negative predictive values of the HEART score were determined as 86.59% (77.3%-93.1%), 71.3% (68.8%-75.5%), 36.4% (32.5%-40.5%), and 96.6%

(94.2%-98.0%), respectively for the low-risk classification, and 43.9%

ported that when six scoring systems were examined, the T-MACS score had the best sensitivity for identifying AMI [16]. Our study adds to the body of knowledge by demonstrating that the T-MACS risk scor- ing method seems to have certain benefits over the HEART score in terms of diagnostic accuracy and AMI exclusion.

The receiver operating characteristic (ROC) analysis revealed a rate of one-month MACE of 2.3% in 217 patients classified as very low risk by T-MACS, with sensitivity and negative predictive values of 93.90% and 97.7%, respectively, for the low-risk group. The incidence of one- month MACE was 3.4% among the 319 patients categorized as low risk by the HEART scoring system, and the sensitivity and negative predictive values of this score were found to be 86.59% and 96.6%, respectively. Body et al. previously found that the HEART score was ineffective in predicting early release in patients with extremely low risk [15]. In another investi- gation, Hreko et al. discovered that both subjects classified as extremely low risk for T-MACS and low risk for HEART score by the T-MACS and HEART scores did not develop disease in the subsequent time [16].

When we compared the predictive value of both scoring systems for one-month MACE, we found that 97.2% of 36 patients classified as high risk by T-MACS had a rate of MACE, with a specificity of 99.77% and a pos- itive predictive value of 97.2%. MACE was seen in 63.7% of 57 patients classified as high risk by HEART, with the specificity and positive predic- tive values for this risk group being 95.14% and 63.2%, respectively. T-MACS, we believe, is more effective than HEART in excluding and diag- nosing MACE in patients presenting to the emergency room with chest discomfort and is hence appropriate for use in this scenario. However, the WESTCOR research found that the HEART score was only marginally more predictive of MACE than the T-MACS score [17]. This might be re- lated to the fact that the two-research used different patient populations. MACE was detected in 1.2-3.8% of those classified as extremely low risk in prior studies examining T-MACS [10,11,15,18]. MACE occurred in

Table 2

Evaluation of AMI , one-month mortality and MACE(major adverse cardiac events) parameters between the HEART score risk classification groups.

HEART score risk classification

p

Low risk

Moderate risk

High risk

n (%)

n (%)

n (%)

Gender

Female

174 (54.5%)

77 (55.8%)

33 (57.9%)

10.886

Male

145 (45.5%)

61 (44.2%)

24 (42.1%)

AMI

Absent

309 (96.9%)

105 (76.1%)

22 (38.6%)

10.000*

Present

10 (3.1%)

33 (23.9%)

35 (61.4%)

One-month mortality status

No mortality

318 (99.7%)

134 (97.1%)

54 (94.7%)

20.003*

Mortality

1 (0.3%)

4 (2.9%)

3 (5.3%)

MACE

Absent

308 (96.6%)

103 (74.6%)

21 (36.8%)

20.000*

Present

11 (3.4%)

35 (25.4%)

36 (63.2%)

1 Chi-square test.

2 Fisher-Freeman-Halton test *p < 0.05.

Table 3

Evaluation of AMI , one-month mortality and MACE parameters between the T-MACS score risk classification groups.

T-MACS score risk classification p

Very low risk

Low risk

Moderate risk

High risk

n (%)

n (%)

n (%)

n (%)

Gender

Female

111 (51.2%)

56 (63.6%)

101 (58.7%)

16 (44.4%)

10.089

Male

106 (48.8%)

32 (36.4%)

72 (41.3%)

20 (55.6%)

AMI

Absent

212 (97.7%)

83 (94.3%)

138 (80.2%)

2 (5.6%)

10.000*

Present

5 (2.3%)

5 (5.7%)

34 (19.8%)

34 (94.4%)

One-month mortality status

No mortality

217 (100%)

87 (98.9%)

167 (97.1%)

34 (94.4%)

20.008*

Mortality

0 (0%)

1 (1.1%)

5 (2.9%)

2 (5.6%)

MACE

Absent

212 (97.7%)

82 (92.3%)

136 (79.1%)

1 (2.8%)

10.000*

Present

5 (2.3%)

6 (6.8%)

36 (20.9%)

35 (97.2%)

1 Chi-square test.

2 Fisher-Freeman-Halton test *p < 0.05.

2.3% of patients classified as extremely low risk by the T-MACS score in our research. According to HEART research, the rate of MACE in the low-risk category was between 1.6 and 3% [13,15,19-21]. The present investigation discovered a MACE rate of 3.4% in this group, which is somewhat higher than the literature. We believe that this scenario is due to the fact that patients’ self-reporting is used to calculate HEART. Patients may offer insufficient or erroneous information or lack suffi- cient knowledge about their own ailments, and anamnesis cannot always be done effectively in emergency situations. We propose that the T-MACS algorithm, which is based on the assessment of four risk categories utilizing anamnesis, signs, symptoms, vital data, and tropo- nin level, has the benefit of being simpler and more reliable to evaluate than HEART and may be utilized effectively in emergency services.

When we compared the two risk categorization methods for ex- cluding AMI, we found that T-MACS was more effective. AMI was seen in 3.1% (n = 10) of patients classified as low-risk by HEART and 2.3% (n = 5) of those classified as very low-risk by T-MACS. Sim- ilarly, the rate of AMI diagnosis was 61.4% (n = 35) for the HEART classification and 94.4% (n = 34) for the T-MACS classification in the high-risk group. Ideal scoring should be straightforward, quick, and effective. The TMACS score has stronger variables than the HEART score, including hypotension, pain characterization, and sweating. The weakness of TMACS is that the area under the curve (AUC) is comparable to the HEART score despite the presence of strong variables.

In terms of mortality, 0.3% (n = 1) of patients in the low-risk group and 5.3% (n = 3) of those in the high-risk group died. While there were

Image of Fig. 1

Fig. 1. Receiver operating characteristic curve of the HEART score for the prediction of one- month MACE .

no deaths in the very low-risk group, mortality occurred at a rate of 5.6% (n = 2) in the high-risk group.

Troponin-based methods for detecting NSTEMI are often inadequate for predicting the development of AMI, death, or the requirement for in- vasive treatment, resulting in delays in patient identification and treat- ment. As a result, it would be advantageous to combine clinical risk rating systems with troponin-based algorithms. Clinical scoring algo- rithms provide a highly safe method of identifying low-risk patients for discharge from cases with suspected diagnoses or those in whom the discharge decision is being questioned. This will also reduce these patients’ hospital stays and bring significant cost savings in terms of di- agnosis and treatment. There has been much attention in recent years in the subject of whether it is safe to discharge a patient with a single tro- ponin reading. The HEART and T-MACS scores are used to determine a patient’s safety after a single blood test. We believe that clinical scoring systems may be utilized safely upon discharge, as Wassie et al. have al- ready recommended [22]. Similarly, Backus et al. claimed in a review of several research that Clinical scoring systems may be used to identify safe release [23]. We expect that this research would encourage doctors to utilize the assessed scoring systems, given it was done with a large number of patients and produced consistent findings.

    1. Limitations

There are some limitations in our study. First, the evaluation of comorbidities of the patients would have allowed a fairer assessment

Image of Fig. 2

Fig. 2. Receiver operating characteristic curve of the T-MACS score for the prediction of one-month MACE (Major Adverse Cardiac Events).

when comparing 1-month mortality between the groups. One of the weaknesses of the study is that it was conducted in a single hospital in a single population, secondary. Thirdly, In the study, the low-risk cate- gory of the T-MACS score and the low-risk category of the HEART score could not be compared. Because the suggestions of the low-risk groups differ in scoring. While T-MACS suggests follow-up for those at low risk, HEART suggests discharge. This is also a significant limitation of our research. Multicenter studies are needed to generalize our results globally. Finally, inclusion of patients’ echocardiographic findings in fu- ture studies may at least provide a more balanced comparison between groups.

  1. Conclusion

Management of patients presenting with chest pain can always be challenging. While clinical decision support systems help physicians to reach the correct diagnosis quickly, they can also create a medical basis for discharge. According to the results of our study, T-MACS score was found to be superior to HEART score for identifying high- risk and very low-risk patients.

Author contributions

Conceptualization and Methodology: SC, BGY,KY,GA; Investiga- tion; OH, KY, DA; Validation: NMH, SC, BGY; Resources: BB, OH, DA, GA; Software: OH, DA, BB, GA Writing – Original Draft; BGY, SC, GA, NMH, KY, DA; Writing – Review & Editing: GA, NMH; Supervision: SC, BGY.

Compliance with ethical standards

Haydarpasa Numune Training and Research Hospital Ethics Com- mittee approved for the study (Ethics Committee protocol number: HNEAH-KAEK 2018/79).

This article has not been previously presented at any event (con- gress, symposium etc.)

Human rights

The principles set out in the Helsinki Declaration were followed. The need for informed consent was waived due to the retrospective nature of the study.

Financial support

This research did not receive any specific grant from funding agen- cies in the public, commercial, or not for profit sectors.

CRediT authorship contribution statement Gurkan Akman: Writing – review & editing, Writing – original draft,

Software, Resources, Methodology, Conceptualization. Nihat Mujdat

Hokenek: Writing – review & editing, Writing – original draft, Valida- tion. Kaan Yusufoglu: Writing – original draft, Methodology, Investiga- tion, Conceptualization. Damla Akman: Writing – original draft, Software, Resources, Investigation. Orhan Hagi: Software, Resources, Investigation. Burcu Bayramoglu: Software, Resources, Data curation. Burcu Genc Yavuz: Writing – original draft, Validation, Supervision, Methodology, Conceptualization. Sahin Colak: Writing – original draft, Validation, Supervision, Methodology, Conceptualization.

Declaration of Competing Interest

None.

Acknowledgement

None.

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