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Identification of very low-risk acute chest pain patients without troponin testing
  1. Lane M. Smith1,
  2. Nicklaus P. Ashburn1,
  3. Anna C. Snavely2,
  4. Jason P. Stopyra1,
  5. Kristin M. Lenoir2,
  6. Brian J. Wells2,
  7. Brian C. Hiestand1,
  8. David M. Herrington3,
  9. Chadwick D. Miller1,
  10. Simon A. Mahler1
  1. 1 Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
  2. 2 Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
  3. 3 Internal Medicine, Section on Cardiovascular Science, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
  1. Correspondence to Dr Lane M. Smith, Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA; lane_smith{at}


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


  • ECG
  • cardiac care, diagnosis
  • cardiac care, acute myocardal infarct
  • cardiac care, acute coronary syndrome
  • acute coronary syndrome

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  • Handling editor Edward Carlton

  • Contributors SAM oversaw the study design, provided key edits to this manuscript and is responsible for the overall content as guarantor. LS and ACS performed the primary data analysis and manuscript writing as well as assisting with the study design. NPA, DMH, BH, CDM, and BJW assisted with study design and manuscript editing. KML assisted with data analysis.

  • Funding Donaghue Foundation and the Association of American Medical Colleges.

  • 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.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Patient consent for publication Not required.

  • Ethics approval The study was approved by our Institutional Review Board (IRB00025114).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All data relevant to the study are included in the article or uploaded as online supplementary information. All original data are maintained by Wake Forest University Health Sciences and is available on request from the corresponding author.