The case

A 64-year-old woman presents to ED with a 2-month history of central chest heaviness on exertion which resolves after approximately 5 minutes of rest. This evening, she developed central chest heaviness while at rest which lasted approximately 30 minutes. Her medical history includes hypertension, for which she takes ramipril 5mg OD, and she has a 20-pack year smoking history.

She is hypertensive and mildly tachycardic. Her cardiorespiratory examination is unremarkable, with no signs of CCF. Her ECG shows some minimal ST depression in the inferior leads, and she has a mildly elevated initial high-sensitivity troponin of 27ng/L. You calculate a HEART score of 5 (intermediate risk). You wonder what the optimal diagnostic pathway for this patient is, and if there is the potential to avoid a lengthy admission and invasive testing.