Emergency department (ED) evaluation of patients with possible acute coronary syndrome (ACS) is frequent and costly.  Of 8-10 million annual ED presentations for chest pain, 40% or more will be deemed low-risk after initial evaluation.  Yet the majority of these patients receive in-hospital noninvasive testing during their index visit.  The proposed study will directly test whether in-hospital evaluation and noninvasive testing should be part of the standard approach to low-risk patients.

The Comparative Health Effectiveness of Strategies Testing Pain Assessment of Ischemia Noninvasively (CHEST PAIN) trial will be a multicenter randomized controlled non-inferiority trial comparing an in-hospital noninvasive testing strategy versus an outpatient follow-up strategy among patients evaluated for possible ACS who meet a standard low-risk definition (proposed sample size ~16,700 subjects).  The in-hospital strategy will consist of standard care with intent to perform a noninvasive test prior to discharge from the hospital.  The outpatient strategy will consist of discharge from the ED within six hours of being seen by an ED physician with outpatient follow-up within seven days.