Multisite Validation of a Strategy to Identify Very Low Risk Emergency Department Patients Without Troponin
Authors' conclusion
Patients with no known coronary artery disease, a nonischemic electrocardiogram, and a HEAR score ≤1 had a missed MACE rate <1%. Troponin testing identified additional patients with MACE but did not significantly improve risk stratification accuracy.
Study context
- Population
- Emergency department patients ≥18 years old with chest pain, HEART Pathway assessments and high-sensitivity troponin testing; HEAR scores completed for patients with no known coronary artery disease and a nonischemic electrocardiogram (November 1, 2020-July 7, 2022)patients, 1,565 with a HEAR score ≤1
- Participants
- 9,105 patients
- Predictors
- History, Electrocardiogram, Age, and Risk factors score ≤1
- Predicted outcome
- 30-day major adverse cardiovascular events (MACE) (death, myocardial infarction [MI], and revascularization)
Methodological detailsWake Forest Chest Pain Registry, 5 U.S. emergency departments, HEAR scores prospectively completed by the treating clinician
- Wake Forest Chest Pain Registry
- 5 U.S. emergency departments
- HEAR scores prospectively completed by the treating clinician
Model performance
As reported in the abstract
Sensitivity of HEAR score ≤1
97.9%
95% CI 96.2–98.9
Negative predictive value of HEAR score ≤1
99.3%
95% CI 98.7–99.6
Further findings
Major adverse cardiovascular events (MACE) among patients with HEAR score ≤1 · 30 days
- MACE among patients with HEAR score ≤1
- 0.7% (11/1,565; 95% CI: 0.4-1.3)
- Deaths
- 3
- MIs
- 8
- Revascularization
- 1
Added value of troponin testing among patients with HEAR score ≤1
- Correctly reclassified with death, MI, or revascularization
- 8
- Troponin elevated among those without MACE
- 74
- Net reclassification improvement index
- 0.7% (95% CI: −0.4 to 1.8)
- Nonsignificant
Patients with HEAR score ≤1
- HEAR score ≤1
- 17.2% (1,565/9,105)
Original publication
Multisite Validation of a Strategy to Identify Very Low Risk Emergency Department Patients Without Troponin. JACC Adv. Published 18 June 2025. doi:10.
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