The current state of the art for EPs includes clinical data, electrocardiograms (ECGs) and cardiac biomarkers5 (Fig. 1). The limitations of using the Goldman prediction rule and the ECG is that they are insensitive indicators of myocardial injury in patients with MI4-9. The sensitivity and specificity of cardiac biomarkers is proportional to the time from onset of chest pain. Cardiac troponin begins to rise within 3-4 hours after the onset of myocardial injury and may remain increased for up to 4-7 days for cTnI and 10-14 days for cTnT10. There is enthusiasm for myoglobin as an early marker; however, myoglobin is non-specific11-16 In ED based trials; cardiac biomarkers have performed well but have not changed the cost and admission rate (false-positives). In 1999, McCord et al9 published a single center prospective cohort study that examined point-of-care cardiac biomarkers during the first 90 minutes and if they could help to exclude AMI in the ED chest pain patient. The post-hoc analysis and resultant negative predictive value (NPV) was 98 to 99% at time 0 minutes, 90 minutes, and 3-hours with various combinations of the three biomarkers including Myoglobin, Troponin I and CK-MB. These results demonstrated a consistency of negative predictive values with both combinations of CK-MB with myoglobin equal to Troponin with myoglobin. In 2004, Fesmire, et al17 reported in another prospective ED cohort study that a 2-hour delta CK-MB level outperforms myoglobin level in the early identification and exclusion of acute MI and can effectively risk-stratify patients for 30-day adverse outcomes. In both of these ED based trials, despite the impressive post-hoc NPV in the McCord et al trial, the cost and admission rate (false-positives) remains the same since the rule-out MI process requires admission and 24 hours of serial cardiac enzyme testing.