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Introduction: The emergency department (ED) evaluation of suspected acute coronary syndrome (ACS) is a common, challenging, and costly task with high clinical stakes. Professional society guidelines recommend early stress testing (within 72 hours of ED visit); however, there are no data to demonstrate improved outcomes with this approach.

Hypotheses: 1.) Early stress testing improves outcomes, and 2.) The association between early stress testing and outcomes is modified by pre-test ACS risk.

Methods: We analyzed prospectively collected registry data from 9 emergency departments on patients with suspected ACS. The primary outcome was 30-day major adverse cardiovascular events (MACE), including all-cause death, acute myocardial infarction, and urgent revascularization. The exposure variable of interest was early stress testing. We used the HEART score to determine pre-test ACS risk (low …