If the patient meets the below criteria for this assessment:

  • 99.9% did not have a heart attack or a death
  • 0.1% did have a heart attack or a death

In Other Words:

  • The risk of a heart attack was 1 in 1000

Risk Assessment Criteria

  • Low risk chest pain according to the judgment of the provider
  • EKG shows no ST elevations or depressions
  • Vital signs are stable (no hypotension)
  • No history of known heart disease
  • Cardiac blood tests (troponin or CK-MB), if performed, are negative (normal)

Source Document: Our Study Analysis Review Spreadsheet

  • Christenson et al. A clinical prediction rule for early discharge of patients with chest pain. Ann Emerg Med. 2006;47(1):1–10.
  • Cullen et al. Comparison of Three Risk Stratification Rules for Predicting Patients With Acute Coronary Syndrome Presenting to an Australian Emergency Department. Heart, Lung, and Circulation 2013;22:844-851.
  • Greenslade et al. Validation of the Vancouver Chest Pain Rule using troponin as the only biomarker. Am J Emerg Med. 2013 Jul;31(7):1103-7.
  • Halpern et al. Cardiac risk factors and risk scores vs cardiac computed tomography angiography: a prospective cohort study for triage of ED patients with acute chest American Journal of Emergency Medicine 31 (2013) 1479–1485.
  • Hess et al. Development of a clinical prediction rulefor 30-day cardiac events in emergency department patients with chest pain and possible acute coronary syndrome. Ann Emerg Med. 2012,59:115–125.
  • Hess et al. The Chest Pain Choice Decision Aid. A Randomized Trial. Circ Cardiovasc Qual Outcomes. 2012;5:251-259.
  • Holly et al. Young Adult Patients With Chest Pain: Utility of the Emergency Department Observation Unit. Ann of Emerg Med. 2011,58:S208-S209. (Research Forum Abstract #94)
  • Jalili et al. Validation of the Vancouver Chest Pain Rule: A Prospective Cohort Study. Acad Emerg Med. 2012; 19:837–842.
  • Kelly et al. What is the incidence of major adverse cardiac events in emergency department chest pain patients with a normal ECG, thrombolysis in myocardial infarction score of zero and initial troponin ≤99th centile: an observational study? Emerg Med J 2013;30:15-18.
  • Lee et al. Long-term survival of emergency department patients with acute chest pain. Am J Cardiol. 1992; 69:145–51.
  • Marsan et al. Evaluation of a Clinical Decision Rule for Young Adult Patients with Chest Pain. Acad Emerg Med. 2005; 12(1): 24-31.
  • Napoli et al. Low-risk chest pain patients younger than 40 years do not benefit from admission and stress testing. Crit Pathw Cardiol. 2013 Dec;12(4):201-3.
  • Scheuermeyer et al. Development and validation of a prediction rule for early discharge of low-risk emergency department patients with potential ischemic chest pain. CJEM 2013; 0(0):1-14.

Narrative: Heart disease remains a major cause of death in western industrialized nations and around the world. It is extremely difficult, however, to reliably forecast which patients with vague or 'soft' symptoms like chest pain will go on to have a true heart problem like a heart attack or death.

In particular chest pain occurring without electrocardiogram changes or biomarker (i.e. troponin) abnormalities is one such 'soft' symptom, and represents the great majority of chest pain patients seen by health care providers. Unfortunately a small proportion of the-se patients will suffer a heart attack or even death, but reliably testing and treating these people without over-testing and over-treating everyone else has proved impossible with current technologies and decision aids.

This review examines the highest quality data available from emergency department evaluation of patients under age 40 who do not have classic cardiac pain, nor classic EKG abnormalities, nor initial biomarker abnormalities*, and who do not have a history of known heart problems. When a physician judged a patient unlikely to have a coronary syndrome and the above criteria were present, the chance of a heart attack or death was extremely small: 2 in 2043. These 2043 patients were pooled from 13 studies. In these data there was 1 heart attack and one death that occurred within 30 days of the initial evaluation. The one death occurred in a patient with metastatic cancer, and it was unclear if the death was related to heart disease. For conservative purposes we counted this death as potentially cardiac.

*Cardiac enzymes used in all contributing studies were either conventional assays of cardiac troponin or CK-MB. Studies using only high-sensitivity troponin assays were excluded. All troponin data in these studies is based on the initial troponin only.

Caveats: These data rely on physician judgment which is generally unstructured, and it is likely that there is considerable variation in judgment. The data are from multiple centers though one center disproportionately contributes, and that is an urban emergency department in Philadelphia where chest pain studies are of unusually high quality with complete data collection and excellent 30-day follow-up. This population may exhibit different characteristics than some others, however the sociodemographic profile of this population (low socio-economic status, high minority) would suggest a higher-than-average risk pro-file rather than a diminished risk profile.



Importantly, because there is no evidence that percutaneous coronary intervention is beneficial outside of emergent use during ST-elevation myocardial infarction (major heart attack), and only weak evidence of a long term benefit with bypass surgery, we do not count 'revascularization' as an important outcome.



It is also important to note that there was variation in the clinical criteria used in the con-tributing trials. In other words, the studies included in this analysis did not all use exactly the same criteria that we use in this review article. At every point in the data collection process where there was ambiguity the most conservative option was chosen. For example, some studies did not specify that the treating physician judge the patient as “low risk”—this criterion was added as a conservative measure to support a low false negative rate.

Author: Harvey Pendell Meyers and David Newman, MD

Published/Updated: September 19, 2010