If the patient has a HEART Score of 0-3 and a negative initial troponin, have a discussion with the patient utilizing the Shared Medical Decision-Making document (Figure 2). Inform the patient that based on validated studies, there is a < 2 % chance of an adverse cardiac event within the next 4-6 weeks. This discussion occurs after the first troponin, not after a second troponin.
The patient chooses amongst the three options listed in the Shared Medical Decision-Making document.
The patient can be offered, and may elect to remain for, a second troponin test and ECG obtained at hour three of the ED stay. If that troponin is negative as well, the patient can be informed that the risk of adverse cardiac event has been lowered to < 1% at 4 weeks. If the second troponin is increased by at least 20% and positive, the patient should be hospitalized for further evaluation.

The patient may elect to be admitted to the hospital or observation unit (based on hospital availability) for observation of occurrence of a cardiac event, or for provocative testing. The patient should be given honest information about the resulting length of stay.

The patient may elect to be discharged immediately after having the single troponin value and knowledge of the < 2% risk as described above.

If the patient chooses either the first or third option and is discharged after either one or two negative troponins, establish followup within one week and save a copy of the signed Shared Decision Making
Document in the chart. Our choice to recommend 1-week follow-up was by consensus and not based on published studies. However, we do not mandate a provocative test at that follow-up visit. The decision for further testing for risk stratification is left to the follow-up physician.
Document medical decision-making and HEART Score in the medical record.
Obtain an ECG at the time of arrival, and repeated along with each troponin, or if symptoms change. If evolving changes are noted on the repeat ECGs, the patient is judged higher risk and admitted. 

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