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The Manchester Acute Coronary Syndromes (MACS) decision rule for suspected cardiac chest pain: derivation and external validation
  1. Richard Body1,2,
  2. Simon Carley2,3,
  3. Garry McDowell1,
  4. Philip Pemberton2,
  5. Gillian Burrows4,
  6. Gary Cook5,
  7. Philip S Lewis6,
  8. Alexander Smith2,
  9. Kevin Mackway-Jones2,3
  1. 1Cardiovascular Sciences Research Group, The University of Manchester, Manchester, UK
  2. 2Emergency Department, Central Manchester University Hospitals Foundation NHS Trust, Manchester, UK
  3. 3Department of Health & Social Care, Manchester Metropolitan University, Manchester, UK
  4. 4Biochemistry Department, Stockport Hospital, Stockport NHS Foundation Trust, Stockport, UK
  5. 5Department of Epidemiology, Stockport Hospital, Stockport NHS Foundation Trust, Stockport, UK
  6. 6Cardiology Department, Stockport Hospital, Stockport NHS Foundation Trust, Stockport, UK
  1. Correspondence to Dr Richard Body, Emergency Department, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK; richard.body{at}


Objective We aimed to derive and validate a clinical decision rule (CDR) for suspected cardiac chest pain in the emergency department (ED). Incorporating information available at the time of first presentation, this CDR would effectively risk-stratify patients and immediately identify: (A) patients for whom hospitalisation may be safely avoided; and (B) high-risk patients, facilitating judicious use of resources.

Methods In two sequential prospective observational cohort studies at heterogeneous centres, we included ED patients with suspected cardiac chest pain. We recorded clinical features and drew blood on arrival. The primary outcome was major adverse cardiac events (MACE) (death, prevalent or incident acute myocardial infarction, coronary revascularisation or new coronary stenosis >50%) within 30 days. The CDR was derived by logistic regression, considering reliable (κ>0.6) univariate predictors (p<0.05) for inclusion.

Results In the derivation study (n=698) we derived a CDR including eight variables (high sensitivity troponin T; heart-type fatty acid binding protein; ECG ischaemia; diaphoresis observed; vomiting; pain radiation to right arm/shoulder; worsening angina; hypotension), which had a C-statistic of 0.95 (95% CI 0.93 to 0.97) implying near perfect diagnostic performance. On external validation (n=463) the CDR identified 27.0% of patients as ‘very low risk’ and potentially suitable for discharge from the ED. 0.0% of these patients had prevalent acute myocardial infarction and 1.6% developed MACE (n=2; both coronary stenoses without revascularisation). 9.9% of patients were classified as ‘high-risk’, 95.7% of whom developed MACE.

Conclusions The Manchester Acute Coronary Syndromes (MACS) rule has the potential to safely reduce unnecessary hospital admissions and facilitate judicious use of high dependency resources.

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 3.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

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