Highlight
• Both ESC 0/1-hour and 0/3-hour high-sensitivity troponin pathways showed similar safety outcomes for ruling out acute coronary syndrome (ACS) in a real-world emergency department setting.
• The shorter 0/1-hour pathway did not significantly increase the proportion of patients discharged within 4 hours compared to the 0/3-hour pathway.
• Safety, measured by major adverse cardiac events (MACE) within 30 days post-discharge, was noninferior in the 0/1-hour arm but overall lower than expected from prior observational studies.
• Central laboratory turnaround times and system constraints limit the efficiency gains expected from accelerated troponin sampling intervals.
