Can a patient with a HEART score of 4, who has been observed overnight with stable vital signs, three negative serial troponin measurements, and six hours of cardiac telemetry, be safely discharged now?

Can This Patient Be Safely Discharged Now?

No, this patient should not be discharged yet—a HEART score of 4 places them in the intermediate-risk category (30-day MACE rate 8-20%), and current guidelines require completion of a full observation protocol with additional testing before safe discharge, regardless of negative troponins and stable telemetry. 1

Why Negative Troponins Don't Override HEART Score 4

• The HEART Pathway mandates both a modified HEAR score 0-3 and negative serial troponins for safe discharge; a HEART score of 4 exceeds the low-risk threshold regardless of troponin results 1
• Data show that intermediate-risk patients (HEART 4-6) with negative troponins still carry a 30-day MACE rate of 8-20%, confirming that negative troponins alone are insufficient to downgrade risk 1
• Low-risk discharge requires a HEART score <3—the threshold is strictly 0-3, not 0-4 1

Required Observation Protocol for HEART Score 4

• Admit for observation in a chest pain unit rather than discharge, as the 2021 AHA/ACC guideline advises for all intermediate-risk patients 1
• Complete an observation period of 6-24 hours with repeat troponin and ECG measurements 2, 1
• Perform serial ECG monitoring during observation to detect new ischemic changes 1
• The current 6 hours of telemetry and three negative troponins represent progress but do not complete the full protocol 1

Additional Testing Required Before Discharge

• After completing the observation period, non-invasive stress testing (exercise ECG, stress echo, or nuclear perfusion) is recommended if the patient remains pain-free and stable 2, 1
• Coronary CT angiography may be used as an alternative anatomic assessment 1
• Discharge can only be contemplated after completion of the observation protocol with negative provocative testing 1

Conditions That Must Be Met for Safe Discharge

• Absence of ischemia on stress testing 1
• Ongoing hemodynamic stability throughout the observation period 1
• No recurrent chest pain during observation 2
• Arrangement of outpatient cardiology follow-up within 72 hours 2

Critical Pitfalls to Avoid

• Do not equate a HEART score of 4 with low risk; the low-risk threshold is strictly 0-3 1
• Serial negative troponins alone do not define low risk when other HEART components raise the score 1
• The modified HEART Pathway's 99.6% NPV applies only to patients with HEAR 0-3 plus negative troponins and does not extend to HEART 4 patients 1
• Six hours of observation is insufficient—guidelines specify 6-24 hours with completion of provocative testing 2, 1

Recommended Next Steps

• Continue observation for at least 6-12 more hours with serial ECG monitoring 2, 1
• Obtain at least one more troponin measurement to complete the serial protocol 2, 1
• Arrange stress testing before discharge if the patient remains stable and pain-free 2, 1
• Only discharge after negative stress test results and confirmed outpatient cardiology follow-up 1