Assessing Chest Pain Using Point-of-Care High-Sensitivity Troponin I in the Emergency Department
Conditions: ACS (Acute Coronary Syndrome)
Sponsor: Wake Forest University Health Sciences

Assessing Chest Pain Using Point-of-Care High-Sensitivity Troponin I in the Emergency 
Department
19NOV2024

Protocol version: 
Template updated 9.24.14 
1 
Study Title: Assessing Chest Pain Using Point-of-Care High-Sensitivity Troponin I in the 
Emergency Department 
Principal Investigator: Simon Mahler, MD, MS 
Co-investigator(s): Michael Supples, MD. David Pearson, MD. Anna Snavely, PhD. 
Sponsor or funding source: Abbott Point of Care 
Background, Rationale and Context 
Current care patterns for the 7 million patients who present to U.S. EDs with acute chest pain 
each year are heterogeneous and costly.1-8 Over 50% of patients with chest pain are hospitalized, 
at a cost of $3 billion annually,5 but ultimately <10% are diagnosed with acute coronary 
syndrome (ACS).9 As one of the most common reasons for ED visits, chest pain evaluations are 
major contributors to ED and hospital crowding; straining health system resources and 
decreasing patient safety, access, and quality of care.2,3,5,6,10,11  Strategies to safely optimize 
hospital resource use for patients with acute chest pain are needed to decrease overcrowding. 
Use of POC testing in the Emergency Department (ED) has been previously established as a 
method to reduce the time-to-disposition-decision (TTD) making for emergency physicians,12,13 
which in-turn can reduce ED LOS14 and time-to-treatment (TTT) of time sensitive conditions, 
such as myocardial infarctions (MIs).15 Recently, new POC high sensitivity cardiac troponin I 
(hs-cTnI) assays have been developed which offer similar diagnostic performance to traditional 
central lab hs-cTnI testing. However, data examining POC hs-cTnI measurement in U.S. ED 
settings are limited. In particular, studies have yet to evaluate the potential impact of POC hs-
cTnI implementation on time to troponin result (TTR), time-to-last-troponin-result (TTLT), 
TTD, TTT, and ED LOS. In addition, limited data exists on how best to implement POC hs-cTnI 
into ED clinical practice, such as whether POC hs-cTnI measures should be paired with a risk 
score or incorporated into an accelerated diagnostic protocol. 
Clinical leaders within the Advocate Health ED and Cardiovascular Service Lines agree that 
POC hs-cTnI holds promise for expediting care with the ED setting but requires pilot testing 
prior to committing the resources needed to fully implement into clinical care. Full 
implementation of POC hs-cTnI, will require purchasing of multiple devices, expensive 
cartridges/reagents, and the hiring of dedicated staff to complete the testing. In order to justify 
costly investments in this new POC technology, we must first establish that their use is able to 
provide return on investment (e.g., reduced ED LOS). Therefore, we propose an observational 
pilot of the Abbott Alinity POC device across 3 Advocate Health EDs. Consistent with prior 
clinical pilots, such as prior testing of new troponin assays, we propose routine collection of a 
single 5ml blood tube from all patients presenting to the ED with chest pain or other symptoms 
concerning for acute coronary syndrome during their normal clinical blood draw and under a 
waiver of informed consent. This blood tube will be used for immediate testing on the Abbott 
Alinity POC device. However, the clinical team will be blinded to POC results and these results 
will not be used for clinical care. Data will be collected on the performance and possible time 
savings of the Abbott Alinity POC hs-cTnI results. These data will be used to inform 
implementation decisions within Advocate Health but are of high interest to Abbott Laboratories 
and the broader scientific community as generalizable knowledge. Therefore, we anticipate 
publishing the results of this observational clinical pilot in a peer-reviewed scientific journal and 
seek IRB approval to do so.  

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Objectives 
The goal of this proposal is to investigate the potential impact of hs-cTnI testing in the 
Emergency Department (ED) setting and exploring how best to integrate POC hs-cTn into ED 
risk stratification workflows. 
 
We hypothesize that the Abbott i-STAT Alinity POC hs-cTnI assay will decrease time-to-result 
(TTR) and ED length of stay (LOS), while increasing ED revenue for patients with acute chest 
pain compared to a strategy of central laboratory hs-cTnI testing. 
 
Aim 1: Test whether the Abbott i-STAT Alinity reduces hs-cTnI TTR and TTLT compared to 
the clinical measures completed in the central laboratory and whether there is high correlation 
between hs-cTnI measurement strategies. 
Aim 2: Determine the potential impact of Abbott i-STAT Alinity use on TTD and ED LOS in all 
enrolled patients and TTT among patients with a Type 1 NSTEMI diagnosis. 
Aim 3: Explore strategies for implementing Abbott i-STAT Alinity hs-cTnI measures into ED 
risk stratification workflow for patients with acute chest pain.  
3a. Evaluate optimal i-STAT Alinity hs-cTnI cut points for predicting index MI and 30-day 
cardiac death or MI. 
3b. Test whether combining i-STAT Alinity hs-cTnI with chest pain risk scores improves 
diagnostic performance.  
3c. Derive an accelerated diagnostic protocol using the i-STAT Alinity hs-cTnI that optimizes 
negative predictive value for 30-day cardiac death or MI and efficacy (the proportion identified 
for early discharge from the ED). 
 
Methods and Measures 
 
Overview: We propose a prospective multisite observational clinical pilot evaluating the 
potential implementation of the Abbott i-STAT Alinity POC hs-cTnI into the current workflow 
of the institutional care process. 
 
• Participants: Adult ED patients with symptoms suggestive of acute coronary syndrome 
undergoing a standard-of-care evaluation possible ACS in the ED including blood testing 
for hs-cTnI (Beckman Coulter) completed in a core laboratory.  
 
• Sites: Three busy tertiary care center EDs will be accrual sites. These include Wake Forest 
Baptist Medical Center (WFBMC), Carolinas Medical Center (CMC) and High Point 
Medical Center (HPMC) EDs.  
 
Subject Selection 
 
Adults (≥18 years old) presenting to the ED with symptoms concerning for ACS and an ECG 
and troponin ordered as part of standard of care, will be eligible for accrual. Patients with acute 
ST changes ≥1mm on ECG or unstable vital signs will be excluded. In addition, patients will be 
required to have a (extra) lithium heparin blood sample collected within ± 5 minutes of their 
clinical draw for hs-cTnI. Patients with central laboratory hs-cTnI testing or a hs-cTnI measure 
resulted prior to study accrual also be excluded.  
 
 

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Inclusion Criteria 
o Age greater than or equal to18 years 
o Symptoms suggestive of acute coronary syndrome 
▪ Acute chest, epigastric, neck, jaw or arm pain or discomfort or 
pressure without apparent non-cardiac source  
▪ Shortness of breath, nausea, vomiting, fatigue/malaise, or  
▪ Other equivalent discomfort suggestive of an MI  
o ECG ordered as part of standard of care 
o At least one troponin collected as standard of care 
o Study specific blood sample collected within ± 5 minutes of clinical draw 
  
Exclusion Criteria 
o STEMI Activation 
o Unstable vitals signs: symptomatic hypotension at the time of enrollment 
(systolic < 90 mm Hg), tachycardia (HR>120), bradycardia (HR<40), and 
hypoxemia (<90% pulse-oximetry on room air or normal home oxygen 
flow rate)  
o Central laboratory hs-cTn testing resulted or in process (>5 minutes) prior 
to study accrual 
o Prior enrollment  
 
Sample Size 
A total of 600 patients will be accrued across the 3 sites.  
 
Interventions and Interactions 
Participants, accrued under a waiver of informed consent, will undergo a standard-of-care 
evaluation for possible ACS in the ED including blood testing for hs-cTnI (Beckman Coulter) 
completed in a central laboratory. During the study period all ED patients with chest pain will 
have an extra lithium heparin blood sample obtained for each troponin test ordered and collected 
in the ED (typically 2, but this may range from 1-3 troponin measures), which will be used for 
immediate hs-cTnI measurement by research personnel using an Abbott i-STAT Alinity. 
Clinicians will be blinded to the POC hs-cTnI results and will base clinical decisions on central 
laboratory hs-cTn measures. Blood draw times, result times for POC and central laboratory 
measures, patient ED arrival, patient ED bedded, ED disposition decision times, and ED 
discharge times will be recorded on all patients. Following each POC hs-cTnI measurement the 
treating attending physician will be surveyed regarding whether a negative or positive POC 
result would change ED disposition or treatment including time stamps to determine estimated 
TTD, ED LOS and TTT for the POC hs-cTnI measurement strategy. Data from these surveys 
will be compared to actual TTD, ED LOS and treatment times based on the central laboratory hs-
cTnI measurement strategy.  

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Usual care: Accrued patients will have routine clinical care with lithium heparin samples 
collected for hs-cTnI measurement sent to the central lab for analysis on the Beckman Coulter 
Access 2 DXI platform. Electronic health record time stamps will be used to determine the result 
time, time of any treatment for type 1 NSTEMI (e.g., heparin ordered), and disposition time 
(e.g., admit or discharge) to calculate actual TTD, ED LOS, and TTT based on the central 
laboratory hs-cTnI measurement strategy. 
 
Setting: Patients will be accrued from three EDs in North Carolina, each with a high prevalence 
of acute chest pain and robust research infrastructure. Across these sites we have broad racial and 
SES representation. The diversity of our sites and their patient populations will ensure that 
patient groups who are traditionally underrepresented are well captured in this trial and will 
ensure the generalizability of trial findings. WF is an academic tertiary care center with an ED 
volume of patients with chest pain exceeding 5,000 per year. CMC is academic tertiary care 
center located in Charlotte NC, which also has a similar high volume of chest pain. HPMC is a 
large community tertiary care center with 24/7 catheterization laboratory capability and an ED 
volume of approximately 4,000 chest pain patients annually 
 
 
Data Collection and Endpoints 
Experienced study staff at each site will collect and enter data using REDCap electronic case 
report forms (eCRFs). Trial eCRFs will be created and maintained by a dedicated database 
manager to facilitate timely, accurate, and complete data entry, and allow monitoring and quality 
control. This will ensure our database is kept up to date and minimize data cleaning. Consistent 
with our prior trials, we will ensure internal and external validity by including data fields 
relevant to the evaluation of patients with acute chest pain across the U.S. Baseline data will be 
collected by site study staff from the patient and clinician (in-person) and supplemented by EHR 
review. Follow-up data will be gathered by research staff by email, telephone follow-up calls, 
EHR review, and outside record requests at 30-days. 
 
The primary outcome will be time-to-result (TTR) of hs-cTnI. TTR will be defined as the time 
from blood collection to result time of the hs-cTnI assay, as recorded by research staff for the i-

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STAT Alinity POC and by the electronic health record for central lab Beckman Coulter Access 2 
hs-cTnI measures. TTR will be collected for each troponin test ordered and collected in the ED 
(typically two tests per patient). A secondary outcome is time-to-last-troponin-result (TTLT), 
which will be defined as the time from ED arrival to the result time of the last hs-cTnI measure 
in the ED (by the POC and central lab strategies). Other secondary outcomes include time-to-
disposition decision (TTD), Time-to-treatment (TTT), and ED length of stay (LOS). TTD is 
defined as the time from the patient being bedded in the ED to provider decision on disposition 
(discharge vs admission). TTT will be defined by the time from the patient being bedded in the 
ED to the provider’s decision to initiate treatment for patients with a Type 1 NSTEMI diagnosis 
(e.g., heparin drip). ED LOS will be defined as the time from ED arrival to disposition 
(discharged, admitted, observation unit, left against medical advice, transfer, etc). We will also 
report ED LOS as bed-hours saved and calculate the associated ED revenue generated based on 
an average of $550 in revenue per bed-hour. In addition, we will monitor safety outcomes, 
including index MI and the composite of cardiac death or MI at index and 30-days. These 
endpoints will be determined by expert adjudicators based on the ACCORD trial definition for 
cardiac death and the Fourth Universal Definition of MI. The safety of diagnostic strategies 
using POC hs-cTnI will be assessed using these outcomes. Furthermore, the efficacy of 
diagnostic strategies, defined as the proportion of patients identified for early discharge, will be 
assessed 
 
 
Adjudication Plan 
The primary outcome, TTR and other time-based secondary outcomes, will not require 
adjudication. However, index and 30-day cardiac death or MI will be adjudicated. In patients 
with an adjudicated MI, reviewers will also determine MI type.  Reviewers with expertise in 
cardiovascular emergencies will have access to the participant’s records, results of relevant 
testing, follow-up call information, records obtained from follow-up, and study definitions, but 
will be blinded to the Abbott Alinity POC hs-cTnI results. Reviewers will complete a REDCap 
reviewer outcome form recording the occurrence of these endpoints. Any disagreements will be 
settled by consensus or involvement of a third independent reviewer. Triggers for adjudication 
will include a report of death, uncertain vital status due to incomplete follow-up information, or 
an elevated hs-cTn value during the follow-up period. We have successfully used these 
adjudication methods in prior trials. 
 
 
Abbott i-STAT Alinity Implementation Strategies:  
We will explore strategies for integrating Abbott i-STAT Alinity hs-cTnI measures into ED risk 
stratification workflows for patients with acute chest pain. This will include finding the optimal 
i-STAT Alinity hs-cTnI cut points for predicting index MI and 30-day cardiac death or MI. 
Specifically, we seek low cut points that achieve ≥ 99% negative predictive value (NPV) while 
maximizing efficacy (proportion identified for early discharge from the ED) and higher cut 
points that achieve a ≥ 65% positive predictive value (PPV). Next, we will determine the 
diagnostic performance (sensitivity, specificity, NPV, PPV, negative and positive likelihood 
ratios and efficacy) for cardiac death or MI of the i-STAT Alinity hs-cTnI when incorporated 
into the history, electrocardiogram, age, risk factors, and troponin (HEART) score and the 
emergency department assessment of chest pain score (EDACS). Finally, we will derive a novel 
accelerated diagnostic protocol using the i-STAT Alinity hs-cTnI that optimizes negative 

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predictive value for 30-day cardiac death or MI and efficacy (the proportion identified for early 
discharge from the ED). 
 
Analysis Plan 
TTR, TTLT, TTD, TTT, and ED LOS for each hs-cTnI measurement strategy (POC vs central 
laboratory) will be compared using paired t-tests and linear mixed models to adjust for potential 
confounders (age, sex, race, cardiovascular risk factors). The correlation between POC i-STAT 
Alinity hs-cTnI vs central laboratory hs-cTnI results will be estimated using Spearman’s 
correlation coefficient. Test characteristics (sensitivity, specificity, NPV, PPV, negative and 
positive likelihood ratios and efficacy) will be reported along with 95% confidence intervals for 
the identified optimal i-STAT Alinity hs-cTnI cut points, for HEART and EDACS when 
incorporating i-STAT Alinity hs-cTnI, and for the novel accelerated diagnostic protocol using 
the i-STAT Alinity hs-cTnI. 
 
Power and Sample Size 
With 600 patients, there will be at least 80% power to detect a difference of 30 minutes in TTR 
between the POC and central laboratory strategies for a range of plausible scenarios. See Section 
9 for additional details. 
 
Human Subjects Protection 
 
Subject Recruitment Methods 
All adult ED patients who arrive with symptoms suggestive of acute coronary syndrome and 
without STEMI could be potentially evaluated for the implementation of the Abbott i-STAT 
Alinity. There is no determination between high vs. low risk for ACS and therefore, all sexes, 
races, and ethnicities will be eligible for inclusion. Pregnant women and minorities will have an 
equal opportunity of being enrolled.  
 
Informed Consent 
 
Written informed consent will not be obtained.  The risk of harm or discomfort that may occur as 
a result of taking part in this observational pilot implementation study is not expected to be more 
than in daily life or from routine physical examinations or tests.  The rights and welfare of study 
will be protected through the use of measures to maintain the confidentiality of study 
information.  Study results will be presented or published in lieu of providing individual subjects 
additional information regarding the study. 
 
Patients who are receiving a standard-of-care evaluation for ACS will have an extra lithium 
heparin blood sample drawn by trained clinical staff at the same time of their collection for the 
standard-of-care hs-cTnl lab. No extra draws will be done outside of the standard-of care 
collection times.  
 
Request of a waiver of consent: 
1) The research involves no more than minimal risk to participants. The risk of harm or 
discomfort that may occur as a result of taking part in this research study is not expected to be 
more than in daily life or from routine physical or psychological examinations or tests. Patients 

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7 
identified for participation in this study/quality surveillance will receive standard care. The 
primary risk of participation is a breach in privacy and confidentiality. 
 
2) The waiver of informed consent will not adversely affect the rights and welfare of the 
participants.  The rights and welfare of participants will be protected through the use of measures 
to maintain the confidentiality of study information.   
 
3) The research could not practicably be carried out without the waiver of informed consent.  To 
determine the effectiveness of POC hs-cTnI testing it must be utilized in a “real world” ED 
patient population. Our pilot implementation design minimizes selection bias, which can threaten 
the validity of an effectiveness study. Requiring informed consent from subjects would likely 
result in a biased sample and reducing the scientific validity of the study results.  Furthermore, it 
would be impractical to perform informed consent on each ED patient undergoing troponin 
testing. Furthermore all participants will receive standard care, so this study does not have risks 
or benefits that will affect the participant’s treatment decisions. 
 
4) Whenever appropriate, the subjects will be provided with additional information after 
participation.  Study results will be presented or published (if possible) in lieu of providing 
individual subjects additional information regarding the study. 
 
 
Confidentiality and Privacy 
Confidentiality will be protected by collecting only information needed to assess study 
outcomes, fully minimizing possible the collection of any information that could directly identify 
subjects, and maintaining all study information in a secure manner.  To help ensure subject 
privacy and confidentiality, only a unique study identifier will appear on the data collection 
form.  Any collected patient identifying information corresponding to the unique study identifier 
will be maintained on a linkage file, store separately from the data.  The linkage file will be kept 
secure, with access limited to designated study personnel.  Following data collection subject 
identifying information will be destroyed 5 years after study completion consistent with data 
validation and study design, producing an anonymous analytical data set.  Data access will be 
limited to study staff.  Data and records will be kept locked and secured, with any computer data 
password protected.  No reference to any individual participant will appear in reports, 
presentations, or publications that may arise from the study. 
 
Only trained and approved study staff will have access to the password protected RedCap where 
electronic case report forms (eCRF) will be completed and physician surveys will be entered. 
Trial eCRFs will be created and maintained by a dedicated database manager to facilitate timely, 
accurate, and complete data entry, and allow monitoring and quality control.  
 
Data and Safety Monitoring 
The principal investigator will be responsible for the overall monitoring of the data and safety of 
study participants.  The principal investigator will be assisted by other members of the study 
staff. 
 
Reporting of Unanticipated Problems, Adverse Events or Deviations 

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Although not expected, any unanticipated problems, serious and unexpected adverse events, 
deviations, or protocol changes will be promptly reported by the principal investigator or 
designated member of the research team to the IRB and sponsor or appropriate government 
agency if appropriate. 
 
References 
1. 
Safavi KC, Li SX, Dharmarajan K, Venkatesh AK, Strait KM, Lin H, Lowe TJ, Fazel R, 
Nallamothu BK, Krumholz HM. Hospital variation in the use of noninvasive cardiac 
imaging and its association with downstream testing, interventions, and outcomes. 
JAMA internal medicine. 2014;174:546-553. doi: 10.1001/jamainternmed.2013.14407 
2. 
Foy AJ, Liu G, Davidson WR, Jr., Sciamanna C, Leslie DL. Comparative effectiveness of 
diagnostic testing strategies in emergency department patients with chest pain: an 
analysis of downstream testing, interventions, and outcomes. JAMA internal medicine. 
2015;175:428-436. doi: 10.1001/jamainternmed.2014.7657 
3. 
Sandhu AT, Heidenreich PA, Bhattacharya J, Bundorf MK. Cardiovascular Testing and 
Clinical Outcomes in Emergency Department Patients With Chest Pain. JAMA internal 
medicine. 2017;177:1175-1182. doi: 10.1001/jamainternmed.2017.2432 
4. 
Smulowitz PB, Barrett O, Hall MM, Grossman SA, Ullman EA, Novack V. Physician 
Variability in Management of Emergency Department Patients with Chest Pain. The 
western journal of emergency medicine. 2017;18:592-600. doi: 
10.5811/westjem.2017.2.32747 
5. 
Sabbatini AK, Nallamothu BK, Kocher KE. Reducing variation in hospital admissions 
from the emergency department for low-mortality conditions may produce savings. 
Health Aff (Millwood). 2014;33:1655-1663. doi: 10.1377/hlthaff.2013.1318 
6. 
Cotterill PG, Deb P, Shrank WH, Pines JM. Variation in chest pain emergency 
department admission rates and acute myocardial infarction and death within 30 days in 
the Medicare population. Acad Emerg Med. 2015;22:955-964. doi: 10.1111/acem.12728 
7. 
Benjamin EJ, Blaha MJ, Chiuve SE, Cushman M, Das SR, Deo R, de Ferranti SD, Floyd 
J, Fornage M, Gillespie C, et al. Heart Disease and Stroke Statistics-2017 Update: A 
Report From the American Heart Association. Circulation. 2017;135:e146-e603. doi: 
10.1161/CIR.0000000000000485 
8. 
Survey NHAMC. 2015 Emergency Department Summary Tables. 
http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2010_ed_web_tables.pdf.: 
CDC; 2015.  
9. 
Mahler SA, Lenoir KM, Wells BJ, Burke GL, Duncan PW, Case LD, Herrington DM, 
Diaz-Garelli JF, Futrell WM, Hiestand BC, et al. Safely Identifying Emergency 
Department Patients With Acute Chest Pain for Early Discharge. Circulation. 
2018;138:2456-2468. doi: 10.1161/CIRCULATIONAHA.118.036528 
10. 
Sharp AL, Kawatkar AA, Baecker AS, Redberg RF, Lee MS, Ferencik M, Wu YL, Shen 
E, Zheng C, Park S, et al. Does Hospital Admission/Observation for Chest Pain Improve 
Patient Outcomes after Emergency Department Evaluation for Suspected Acute 
Coronary Syndrome? J Gen Intern Med. 2021. doi: 10.1007/s11606-021-06841-2 
11. 
Natsui S, Sun BC, Shen E, Redberg RF, Ferencik M, Lee MS, Musigdilok V, Wu YL, 
Zheng C, Kawatkar AA, et al. Higher Emergency Physician Chest Pain Hospitalization 
Rates Do Not Lead to Improved Patient Outcomes. Circulation Cardiovascular quality 
and outcomes. 2021;14:e006297. doi: 10.1161/CIRCOUTCOMES.119.006297 
12. 
Asha SE, Chan AC, Walter E, Kelly PJ, Morton RL, Ajami A, Wilson RD, Honneyman D. 
Impact from point-of-care devices on emergency department patient processing times 
compared with central laboratory testing of blood samples: a randomised controlled trial 

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and cost-effectiveness analysis. Emerg Med J. 2014;31:714-719. doi: 
10.1136/emermed-2013-202632 
13. 
Lee EJ, Shin SD, Song KJ, Kim SC, Cho JS, Lee SC, Park JO, Cha WC. A point-of-care 
chemistry test for reduction of turnaround and clinical decision time. Am J Emerg Med. 
2011;29:489-495. doi: 10.1016/j.ajem.2009.11.020 
14. 
Singer AJ, Ardise J, Gulla J, Cangro J. Point-of-care testing reduces length of stay in 
emergency department chest pain patients. Ann Emerg Med. 2005;45:587-591. doi: 
10.1016/j.annemergmed.2004.11.020 
15. 
Renaud B, Maison P, Ngako A, Cunin P, Santin A, Herve J, Salloum M, Calmettes MJ, 
Boraud C, Lemiale V, et al. Impact of point-of-care testing in the emergency department 
evaluation and treatment of patients with suspected acute coronary syndromes. Acad 
Emerg Med. 2008;15:216-224. doi: 10.1111/j.1553-2712.2008.00069.x 
 
Appendix 
ACUTE Trial: Provider Survey  
 
 
 
 
 
 
Patient 
________________________                                                                                      
Time Stamp 
____________________ 
Troponin Draw: 
first, second, third 
 
Please respond to the following statements: 
1. An ELEVATED point-of-care high sensitivity troponin result from the i-STAT device would impact 
your disposition decision for this patient now. 
a) Strongly Agree  
b) Agree  
c) Neutral 
d) Disagree 
e) Strongly Disagree 
 
2. If the result was ELEVATED (e.g., >100 ng/L) you would admit this patient now.  
a) Strongly Agree  
b) Agree  
c) Neutral 
d) Disagree 
e) Strongly Disagree 
IF a or b – please estimate the time of your admission decision ____________ 
IF c, d, or e –please explain why you would not be ready to admit this patient (circle all that 
apply): i. additional troponin needed, ii. other labs pending, iii. imaging pending, iv. Other:  
__________________________________ 
 
3. If the result was ELEVATED (e.g., >100 ng/L) you would begin treatment of NSTEMI now, such 
as aspirin and an anticoagulant (e.g., heparin). 
a) Strongly Agree:  
b) Agree  
c) Neutral 
d) Disagree 
e) Strongly Disagree 
 
IF a or b – please estimate the time of your treatment decision ____________ 

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IF  c, d, or e –please explain why you would not be ready to treat this patient 
_________________ 
 
4. A NEGATIVE/NORMAL point-of-care high sensitivity troponin result from the i-STAT device 
would impact your disposition of this patient. 
a) Strongly Agree  
b) Agree  
c) Neutral 
d) Disagree 
e) Strongly Disagree 
 
5. If the result was NEGATIVE/NORMAL (e.g., <6 ng/L) you would discharge this patient now.  
a) Strongly Agree  
b) Agree  
c) Neutral 
d) Disagree 
e) Strongly Disagree 
IF a or b – please estimate the time of your discharge decision ____________  
IF c, d, or e –please explain why you are not be ready to discharge this patient (circle all that 
apply): i. additional troponin needed, ii. other labs pending, iii. imaging pending, iv. Other:  
_________________________________ 
 
6. I have high confidence in the accuracy of high sensitivity troponin measures from an FDA 
approved point-of-care device. 
a) Strongly Agree  
b) Agree  
c) Neutral/Don’t Know 
d) Disagree 
e) Strongly Disagree 
Patient ID_________________              
Date______________ 
HEAR Score 
HISTORY: (2 points max) 
High-Risk Features: 
Yes    No 
    
     Middle- or left-sided 
    
     Heavy/Tight/Pressure chest pain 
    
     Diaphoresis 
    
     Radiation 
    
     N/V 
    
     Exertional 
    
     Relief of symptoms by sublingual nitrates 
Low-Risk Features: 
Yes   No 
    
     Well localized 
    
     Sharp pain 
                  Non-exertional 
                  No diaphoresis 
                  No N/V 
 
 2 Points 
(mostly high-risk 
features) 
 
 
 
 
 1 Point 
(mixture of high and
low-risk features)  
 
 
 
 
 0 Points 
(mostly low-risk 
features)  
ECG: (1 point max) 
 Yes   No 
    
      Normal 
 
 
 0 Points 

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      Repolarization abnormalities/Early repolarization 
    
      Non-specific T wave changes 
    
      Non-specific ST-segment depression or elevation 
    
      Bundle branch blocks 
    
      Pacemaker rhythms 
    
      LVH (left ventricular hypertrophy) 
    
      Digoxin effect            
  
 
 
 1 Point 
AGE: (2 points max) 
 ≥ 65 
 45-64 
 ≤44 
 
 2 Points 
 1 Point 
 0 Points 
RISK FACTORS: (2 points max) 
Yes to any of the following: 
Yes   No 
    
      Prior stroke 
    
      Peripheral arterial disease (PAD)  
    
      3 or more of the following risk factors: 
 
 
 
 2 Points 
 
 
Yes   No 
    
      Obesity (BMI ≥ 30) 
    
      Current or recent (≤ 90 days) smoker 
    
      Currently treated diabetes mellitus 
    
      Family history of CAD (1st degree relative <55 yo) 
    
      Diagnosed and/or treated hypertension 
    
      Hypercholesterolemia 
 
 
 
 
 
1-2 of above Risk factors: 
 
        
 1 Point 
No risk factors 
 
        
 0 Points 
HEAR Score (no Troponin) (total points) 
 
____/7 
Add points from each category above 
      ≤ 3 = low risk    4-6= moderate risk   7= high risk 
Yes 
No 
Acute Ischemic ECG1 
Known CAD2 
 
1 New contiguous T wave inversions or ST depression ≥1mm 
2 Prior MI, stents, CABG, PCI, or ≥70% coronary obstruction 
 
 
 
Attending Name (Printed)_________________________        Attending Signature         
__________________________ 
 
 

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Patient ID_________________              
Date______________ 
 
 
Treating Provider Form- Subject Information  
Did the Patient Have Chest Pain > 3 Hours Prior to Arrival?   
 
 
Yes 
No                                     
 
Has the Chest Pain Been Constant for >3 hours?  
 
 
 
Yes 
No 
 
What was the Duration of Most Recent Episode of Chest Pain?  
___________ Hours  
 
Does the Patient have Any of the Following Associated Symptoms?
 
 
Select All That Apply 
 
 
 
 
 
Reproducible Chest Pain 
 
 
 
 
 
 
Yes 
No 
 
Pleuritic Chest Pain  
 
 
 
 
 
 
 
Yes 
No 
 
Radiation of Chest Pain   
 
 
 
 
 
 
 
 
 
More than 2 Anginal Events in Past 24 Hours 
 
 
 
 
Yes 
No 
 
Use of Aspirin in Past 7 Days 
 
 
 
 
 
 
Yes 
No 
 
Ongoing Pain 
 
 
 
 
 
 
 
 
Yes 
No 
 
Crescendo Pain  
 
 
 
 
 
 
 
Yes 
No 
 
Training of Provider (Circle One):  
 
PY1 
PY2 
PY3 
PY4 
Attending  
Advanced Practicing Provider  Fellow  
 
Provider Completing Form:  
 
Print: __________________________________     Signature: ___________________________________ 
 
___ Chest Pain 
___ SOB 
___ Diaphoresis 
___ Nausea 
___ Vomiting 
___ Lightheaded/ Syncope 
___ Palpitations 
Other: ________________ 
___ Left Arm/ Shoulder 
___ Right Arm/ Shoulder 
___ Both Arms/ Shoulders 
___ Jaw 
___ Epigastrium 
___ Back 
___ None