{"doi":"10.1016/j.jacadv.2025.101913","title":"Multisite Validation of a Strategy to Identify Very Low Risk Emergency Department Patients Without Troponin","abstract":"BACKGROUND: Patients with chest pain who are very low risk, defined by a History, Electrocardiogram, Age, and Risk factors (HEAR) score ≤1, may not require troponin testing. OBJECTIVES: The aim of this study was to determine whether troponin testing is needed in patients with HEAR scores ≤1 in a multisite U.S. METHODS: We conducted an observational cohort study using the Wake Forest Chest Pain Registry. Patients ≥18 years old with HEART Pathway assessments and high-sensitivity troponin testing were accrued from 5 U.S. emergency departments (November 1, 2020-July 7, 2022). HEAR scores were prospectively completed by the treating clinician for patients with no known coronary artery disease and a nonischemic electrocardiogram. The outcome was 30-day major adverse cardiovascular events (MACE) (death, myocardial infarction [MI], and revascularization). The proportion of patients with HEAR scores ≤1 with MACE within 30 days was determined, and test characteristics were calculated. The net reclassification improvement index for troponin testing among patients with HEAR scores ≤1 was determined. RESULTS: Among 9,105 patients, 17.2% (1,565/9,105) had a HEAR score ≤1. At 30 days, MACE occurred in 0.7% (11/1,565; 95% CI: 0.4-1.3), with 3 deaths, 8 MIs, and 1 revascularization. The sensitivity and negative predictive value for 30-day MACE in patients with a HEAR score ≤1 were 97.9% (95% CI: 96.2-98.9) and 99.3% (95% CI: 98.7-99.6). Troponin testing correctly reclassified 8 with death, MI, or revascularization. Troponin was elevated among 74 without MACE, yielding a nonsignificant net reclassification improvement index of 0.7% (95% CI: -0.4 to 1.8). CONCLUSIONS: 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.","journal":"JACC Advances","year":2025,"id":523656,"datarank":0.0,"base_score":0.0,"endowment":0.0,"self_citation_contribution":0.0,"citation_network_contribution":0.0,"self_endowment_contribution":0.0,"citer_contribution":0.0,"corpus_percentile":null,"corpus_rank":null,"citation_count":4,"citer_count":0,"citers_with_citation_signal":0,"citers_with_endowment":0,"datacite_reuse_total":0,"is_dataset":false,"is_dataset_confidence":0.9439,"is_data_producer":false,"deposit_databanks":null,"is_oa":true,"file_count":0,"downloads":0,"has_version_chain":false,"published_date":"2025-01-01","fair_score":null,"fair_percentile":null,"algorithm_id":"datarank_citation_only_1hop_v6","ranking_scope":"data_only","authors":[{"id":317119,"name":"Anna C. Snavely","orcid":"0000-0001-6916-4255","position":1,"is_corresponding":false},{"id":1396572,"name":"Akalya Villenthi","orcid":null,"position":2,"is_corresponding":false},{"id":1273744,"name":"Tara Hashemian","orcid":null,"position":3,"is_corresponding":false},{"id":689594,"name":"Michael Supples","orcid":"0000-0001-5999-4554","position":4,"is_corresponding":false},{"id":833733,"name":"Simon A. Mahler","orcid":"0000-0003-2199-4078","position":5,"is_corresponding":false},{"id":865710,"name":"Nicklaus P. Ashburn","orcid":"0000-0002-3466-8813","position":0,"is_corresponding":true}],"reference_count":46,"raw_metadata":null,"created_at":"2026-07-19T02:50:03.004175Z","pmid":"40554408","pmcid":null,"fwci":null,"citation_percentile":null,"influential_citations":0,"oa_status":null,"license":null,"views":0,"total_file_size_bytes":0,"version_count":0,"fair_f":null,"fair_a":null,"fair_i":null,"fair_r":null,"fair_zscore":null,"fair_rationale":null,"fair_model":null,"fair_agent_version":null,"fair_fulltext_source":null,"fair_has_llm":null,"fair_computed_at":null,"clinical_trials":[],"software_tools":[],"db_accessions":[],"linked_datasets":[],"topics":[]}