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Background: To determine if the European Society of Cardiology 0/1-hour (ESC 0/1-h) algorithm with high-sensitivity cardiac troponin T (hs-cTnT) meets the ≥99% negative predictive value (NPV) safety threshold for 30-day cardiac death or myocardial infarction (MI) in older, middle-aged and young subgroups., Methods: We conducted a subgroup analysis of adult emergency department patients with chest pain prospectively enrolled from eight US sites (January 2017 to September 2018). Patients were stratified into rule-out, observation and rule-in zones using the hs-cTnT ESC 0/1-h algorithm and classified as older (≥65 years), middle aged (46-64 years) or young (21-45 years). Patients had 0-hour and 1-hour hs-cTnT measures (Roche Diagnostics) and a History, ECG, Age, Risk factor and Troponin (HEART) score. Fisher's exact tests compared rule-out and 30-day cardiac death or MI rates between ages. NPVs with 95% CIs were calculated for the ESC 0/1-h algorithm with and without the HEART score., Results: Of 1430 participants, 26.9% (385/1430) were older, 57.4% (821/1430) middle aged and 15.7% (224/1430) young. Cardiac death or MI at 30 days occurred in 12.8% (183/1430). ESC 0/1-h algorithm ruled out 35.6% (137/385) of older, 62.1% (510/821) of middle-aged and 79.9% of (179/224) young patients (p<0.001). NPV for 30-day cardiac death or MI was 97.1% (95% CI 92.7% to 99.2%) among older patients, 98.4% (95% CI 96.9% to 99.3%) in middle-aged patients and 99.4% (95% CI 96.9% to 100%) among young patients. Adding a HEART score increased NPV to 100% (95% CI 87.7% to 100%) for older, 99.2% (95% CI 97.2% to 99.9%) for middle-aged and 99.4% (95% CI 96.6% to 100%) for young patients., Conclusions: In older and middle-aged adults, the hs-cTnT ESC 0/1-h algorithm was unable to reach a 99% NPV for 30-day cardiac death or MI unless combined with a HEART score., Trial Registration Number: NCT02984436., Competing Interests: Competing interests: ACS receives funding from Abbott, HRSA (1H2ARH399760100) and AHRQ (R01HS029017). JS receives research funding from HRSA (H2ARH39976-01-00), The Duke Endowment, Roche Diagnostics, Abbott Laboratories, Pathfast, Genetesis, Cytovale, Forest Devices, Vifor Pharma and Chiesi Farmaceutici. SAM receives funding/support from Roche Diagnostics, Abbott Laboratories, QuidelOrtho, Siemens, Grifols, Pathfast, Genetesis, Cytovale, The Duke Endowment, Beckman Coulter, Comprehensive Research Associates, Brainbox, HRSA (1H2ARH399760100) and AHRQ (R01HS029017). He is a consultant for Roche, QuidelOrtho, Abbott, Siemens, Genetesis, Inflammatix, Radiometer and Amgen and is the chief medical officer for Impathiq. BA receives research funding/support from Roche Diagnostics, Siemens and Beckman Coulter. He is a consultant for Roche Diagnostics. BM has research support from the NIH (5K08HL130546) and Roche Diagnostics. She has served as a consultant for Roche Diagnostics. JM receives research funding/support from Beckman Coulter, Roche Diagnostics, Abbott Laboratories and Siemens. He is a consultant for Beckman Coulter, Roche Diagnostics and Siemens. RGW received research funding from Regeneron Pharmaceuticals, Lilly USA, BioAge Labs, Roche Diagnostics, Global Blood Therapeutics, Novartis Pharmaceuticals, Egetis Therapeutics, EndPoint Health, Blade Therapeutics, Janssen R&D, ProvePharma and Pfizer. He has received research funding from CoapTech through an NIH/NIDDK grant (R44DK115325). He has received research support in the form of equipment and supplies from Cepheid and Eldon Biologicals. He is an uncompensated advisor to CSL Behring. RC is a consultant for and receives funding/support from Roche Diagnostics, Siemens Healthineers, Beckman Coulter Diagnostics, Becton Dickinson and Co, Quidel and Sphingotec., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Millions of patients present to US EDs each year with symptoms concerning for acute coronary syndrome (ACS), but fewer than 10% are ultimately diagnosed with ACS. Well-tested and externally validated accelerated diagnostic protocols were developed to aid providers in risk stratifying patients with possible ACS and have become central components of current ED practice guidelines. Nevertheless, the fear of missing ACS continues to be a strong motivator for ED providers to pursue further testing for their patients. An ethical dilemma arises when the provider must balance the risk of ACS if the patient is discharged compared with the potential harms caused by a cardiac workup. Providers should be familiar with the ethical principles relevant to this dilemma in order to determine what is in the best interests of the patient., Competing Interests: Competing interests: SAM receives research funding from Roche Diagnostics, Abbott Laboratories, Ortho Clinical Diagnostics, Creavo Medical Technologies, Siemens, Grifols, Pathfast, AHRQ, PCORI, NIDA and NHLBI (1RO1HL118263-01), and HRSA (1H2ARH399760100). He is a consultant for Roche and Amgen and the Chief Medical Officer for Impathiq Inc. JPS receives research funding from Abbott Laboratories and Roche Diagnostics., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The HEART Pathway combines a History ECG Age Risk factor (HEAR) score and serial troponins to risk stratify patients with acute chest pain. However, it is unclear whether patients with HEAR scores of < 1 require troponin testing. The objective of this study is to measure the major adverse cardiac event (MACE) rate among patients with < 1 HEAR scores and determine whether serial troponin testing is needed to achieve a miss rate <1%., Methods: A secondary analysis of the HEART Pathway Implementation Study was conducted. HEART Pathway risk assessments (HEAR scores and serial troponin testing at 0 and 3 hours) were completed by the providers on adult patients with chest pain from three US sites between November 2014 and January 2016. MACE (composite of death, myocardial infarction (MI) and coronary revascularisation) at 30 days was determined. The proportion of patients with HEAR scores of < 1 diagnosed with MACE within 30 days was calculated. The impact of troponin testing on patients with HEAR scores of < 1 was determined using Net Reclassification Improvement Index (NRI)., Results: Providers completed HEAR assessments on 4979 patients and HEAR scores<1 occurred in 9.0% (447/4979) of patients. Among these patients, MACE at 30 days occurred in 0.9% (4/447; 95% CI 0.2% to 2.3%) with two deaths, two MIs and 0 revascularisations. The sensitivity and negative predictive value for MACE in the HEAR < 1 was 97.8% (95%CI 94.5% to 99.4%) and 99.1% (95% CI 97.7% to 99.8%), respectively, and were not improved by troponin testing. Troponin testing in patients with HEAR < 1 correctly reclassified two patients diagnosed with MACE, and was elevated among seven patients without MACE yielding an NRI of 0.9% (95%CI -0.7 to 2.4%)., Conclusion: These data suggest that patients with HEAR scores of 0 and 1 represent a very low-risk group that may not require troponin testing to achieve a missed MACE rate <1%. Trial registration number NCT02056964., Competing Interests: Competing interests: SAM receives research funding from Roche Diagnostics, Abbott Point of Care, Ortho Clinical Diagnostics, Creavo Medical Technologies, PCORI, AHRQ and NHLBI (1 R01 HL11826301). He is a consultant for Roche Diagnostics and Amgen. SAM is the chief medical officer for Impathiq. JPS receives research funding from Roche Diagnostics and Abbott Point of Care. LS receives research funding from Forest Devices and the NHLBI (1 R01 HL144624-01). CDM receives research funding from Abbott, Siemens, NHLBI 118263, Creavo Medical Technologies., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The History Electrocardiogram Age Risk factor Troponin (HEART) Pathway and Emergency Department Assessment of Chest pain Score (EDACS) are validated accelerated diagnostic pathways designed to risk stratify patients presenting to the emergency department with chest pain. Data from large multisite prospective studies comparing these accelerated diagnostic pathways are limited., Methods: The HEART Pathway Implementation is a prospective three-site cohort study, which accrued adults with symptoms concerning for acute coronary syndrome. Physicians completed electronic health record HEART Pathway and EDACS risk assessments on participants. Major adverse cardiac events (death, myocardial infarction and coronary revascularisation) at 30 days were determined using electronic health record, insurance claims and death index data. Test characteristics for detection of major adverse cardiac events were calculated for both accelerated diagnostic pathways and McNemar's tests were used for comparisons., Results: 5799 patients presenting to the emergency department were accrued, of which HEART Pathway and EDACS assessments were completed on 4399. Major adverse cardiac events at 30 days occurred in 449/4399 (10.2%). The HEART Pathway identified 38.4% (95% CI 37.0% to 39.9%) of patients as low-risk compared with 58.1% (95% CI 56.6% to 59.6%) identified as low-risk by EDACS (p<0.001). Major adverse cardiac events occurred in 0.4% (95% CI 0.2% to 0.9%) of patients classified as low-risk by the HEART Pathway compared with 1.0% (95% CI 0.7% to 1.5%) of patients identified as low-risk by EDACS (p<0.001). Thus, the HEART Pathway had a negative predictive value of 99.6% (95% CI 99.1% to 99.8%) for major adverse cardiac events compared with a negative predictive value of 99.0% (95% CI 98.5% to 99.3%) for EDACS., Conclusions: EDACS identifies a larger proportion of patients as low-risk than the HEART Pathway, but has a higher missed major adverse cardiac events rate at 30 days. Physicians will need to consider their risk tolerance when deciding whether to adopt the HEART Pathway or EDACS accelerated diagnostic pathway., Trial Registration Number: NCT02056964., Competing Interests: Competing interests: SM also receives research funding/support from Abbott Point of Care, Roche Diagnostics, Siemens, PCORI and NHLBI (1 R01 HL118263-01, L30 HL120008). SM is the Chief Medical Officer for Impathiq Inc. JS receives research funding/support from Abbott Point of Care, Roche Diagnostics and and NHLBI (1 R01 HL118263-01). CM receives research funding/support from Siemens, Abbott Point of Care and 1 R01 HL118263. ACS receives research funding from NHLBI (1 R01 HL118263-01)., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)