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Circulation. 2021;144:e368–e454. DOI: 10.1161/CIR.0000000000001029 November 30, 2021 e391 CLINICAL STATEMENTS AND GUIDELINES Table 6. Sample Clinical Decision Pathways Used to Define Risk HEART Pathway31 EDACS44 ADAPT (mADAPT)45 NOTR34 2020 ESC/hs-cTn*46,47 2016 ESC/ GRACE11,38 Target population Suspected ACS Suspected ACS, CP >5 min, planned serial troponin Suspected ACS, CP >5 min, planned observation Suspected ACS, ECG, troponin ordered Suspected ACS, stable Suspected ACS, planned serial troponin Target outcome ↑ ED discharge without increasing missed 30-d or 1-y MACE ↑ ED discharge rate without increasing missed 30-d MACE ↑ ED discharge rate without increasing missed 30-d MACE ↑ Low-risk classification without increasing missed 30-d MACE Early detection of AMI; 30-d MACE Early detection of AMI Patients with primary outcome in study population, % 6–22 12 15 5–8 9.8 10–17 Troponin cTn, hs-cTn hs-cTn cTn, hs-cTn cTn, hs-cTn hs-cTn cTn, hs-cTn Variables used History ECG Age Risk factors Troponin (0, 3 h) Age Sex Risk factors History Troponin (0, 2 h) TIMI score 0-1 No ischemic ECG changes Troponin (0, 2 h) Age Risk factors Previous AMI or CAD Troponin (0, 2 h) History ECG hs-cTn (0, 1 or 2 h) Age HR, SBP Serum Cr Cardiac arrest ECG Cardiac biomarker Killip class Risk thresholds: Low risk HEART score <3 Neg 0, 3-h cTn Neg 0, 2-h hs-cTn EDACS score <16 Neg 0, 2 h hs-cTn No ischemic ECG Δ TIMI score 0 (or <1 for mADAPT) Neg 0, 2-h cTn or hs-cTn No ischemic ECG Δ Age <50 y <3 risk factors Previous AMI or CAD Neg cTn or hscTn (0, 2 h) Initial hs-cTn is “very low” and Sx onset >3 h ago Or Initial hs-cTn “low” and 1– or 2-h hs-cTn Δ is “low” Chest pain free, GRACE <140 Sx <6 h - hs-cTn <ULN (0, 3 h) Sx >6 h - hs-cTn <ULN (arrival) Intermediate risk HEART score 4-6 NA TIMI score 2-4 NA Initial hs-cTn is between “low” and “high” And/Or 1- or 2-h hs-cTn Δ is between low and high thresholds T0 hs-cTn = 12–52 ng/L or 1-h Δ = 3–5 ng/L High risk HEART score 7-1048,49 NA TIMI score 5-749 NA Initial hs-cTn is “high” Or 1- or 2-h hs-cTn Δ is high T0 hs-cTn >52 ng/L Or Δ 1 h >5 ng/L Performance ↑ ED discharges by 21% (40% versus 18%) ↓ 30-d objective testing by 12% (69% versus 57%) ↓ length of stay by 12 h (9.9 versus 21.9 h) More patients identified as low risk versus ADAPT (42% versus 31%) ADAPT: More discharged ≤6 h (19% versus 11%) 30-d MACE sensitivity =100% 28% eligible for ED discharge AMI sensitivity >99% 62% Ruled out (0.2% 30-d MACE) 25% Observe 13% Rule in AMI sensitivity >99% 30-d MACE not studied AMI sensitivity, % 100 100 100 100 >99 96.7 cTn accuracy: 30-d MACE sensitivity, % 100 100 100 100 NA NA hs-cTn accuracy: 30-d MACE sensitivity, % 95 92 93 99 99 -- ED discharge, % 40 49 19 (ADAPT) 39 (mADAPT) 28 -- -- ACS indicates acute coronary syndrome; ADAPT, Accelerated Diagnostic protocol to Assess chest Pain using Troponins; AMI, acute myocardial infarction; CP, chest pain or equivalent; Cr, creatinine; cTn, cardiac troponin; hs-cTn, high-sensitivity cardiac troponin; ECG, electrocardiogram; ED, emergency department; EDACS, emergency department ACS; ESC, European Society of Cardiology; GRACE, Global Registry of Acute Coronary Events; HEART, history, ECG, age, risk factors, troponin; HR, heart rate; hs, high sensitivity; MACE, major adverse cardiovascular events; mADAPT, modified (including TIMI scores of 1) ADAPT; NA, not applicable; neg, negative; NICE, National Institute for Health and Clinical Excellence; NOTR, No Objective Testing Rule; SBP, systolic blood pressure; SSACS, symptoms suggestive of ACS; Sx, symptoms; and ULN, upper limit of normal. *The terms “very low,” “low,” “high,” “1 h Δ,” and “2 h Δ” refer to hs-cTn assay–specific thresholds published in the ESC guideline.46,47 Downloaded from http://ahajournals.org by on October 7, 2026