Multisite Validation of a Strategy to Identify Very Low-Risk ED Patients Without Troponin Testing
Nicklaus P. Ashburn et al.
JACC: Advances, June 18, 2025
[DOI not provided]
🩺 Clinical Takeaway:
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In ED patients with:
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HEAR score ≤1
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No CAD
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Nonischemic ECG
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👉 Troponin testing may be unnecessary, as MACE risk is <1%.
👉 This approach could streamline chest pain evaluation and reduce unnecessary testing in low-risk patients.
🧪 Methods:
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Multisite observational cohort study from 5 U.S. EDs using the Wake Forest Chest Pain Registry (Nov 2020–Jul 2022).
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Inclusion: Adults (≥18) with HEART Pathway assessments and high-sensitivity troponin (hs-cTn) testing.
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Exclusion: Known CAD or ischemic ECG.
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Primary outcome: 30-day MACE (death, MI, revascularization).
📊 Key Findings:
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9,105 total patients, 1,565 (17.2%) had HEAR score ≤1.
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30-day MACE occurred in 0.7% of very low-risk group (11/1,565):
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3 deaths
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8 MIs
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1 revascularization
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Diagnostic performance (HEAR score ≤1):
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Sensitivity: 97.9% (95% CI: 96.2–98.9)
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NPV: 99.3% (95% CI: 98.7–99.6)
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Troponin testing:
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Correctly reclassified 8 MACE cases
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Elevated in 74 patients without MACE
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Net reclassification improvement: 0.7% (not statistically significant)
Ashburn, N.P., Snavely, A.C., Villenthi, A., Hashemian, T., Supples, M.W. and Mahler, S.A., 2025. Multisite Validation of a Strategy to Identify Very Low Risk Emergency Department Patients Without Troponin. JACC: Advances, 4(7), p.101913.