Abstract Body (Do not enter title and authors here): Introduction: The HEART score, developed over 15 years ago, aimed to guide the disposition decision for patients presenting to the emergency department (ED) with chest pain. A main concern for these patients is avoiding a missed myocardial infarction (MI). The original studies to develop the HEART score relied on an older generation of troponin assays, however high-sensitivity troponin assays are now widely used and have greatly enhanced the detection of MI. There is uncertainty in the utility of using the HEART score in the current era.

Question: Can high-sensitivity troponin assays rule out risk of MI and death in patients with a moderate or high HEART score?

Methods: We analyzed patients presenting to the University of Florida Shands Hospital, a tertiary medical center, with chest pain, high-sensitivity troponin I levels below the 99th percentile, and moderate or high-risk HEART score; 4-6 and 7+, respectively. Patients were recruited from June 2019 to December 2023. The HEART score was collected prospectively as part of our chest pain registry. We calculated the negative predictive value (NPV) for the outcomes of MI and cardiovascular death or death from an unknown cause at 30 days.

Results: We included 1329 patients. The average age was 58.9 years and 52.7% were women. High sensitivity troponin I was negative (<6 ng/L) in 892 patients and detectable but less than the 99th percentile (<15 ng/L for women and <20 ng/L for men) in 437 patients. A total of 1222 patients had moderate and 107 patients had high HEART scores. There were two (0.2%) MIs and one (0.1%) death in patients with negative troponin levels and no MI or death in patients with detectable levels below the 99th percentile. The NPV for negative or detectable troponin levels below the 99th percentile for both outcomes combined was 99.8% in the cohort overall, 99.8% in patients with a moderate HEART score, and 100% in patients with a high HEART score (Figure 1).

Conclusion: In patients with chest pain and a moderate or high HEART score, negative or detectable high-sensitivity troponin levels below the 99th percentile have a high NPV in ruling out MI and death at 30 days. These findings can inform decision making in the ED for chest pain patients.