Abstract Decision making in acute chest pain remains challenging despite normal (<99th percentile) high-sensitivity troponin (hs-cTn). Some studies suggest that undetectable hs-cTn, far below the 99th percentile, might rule out acute coronary syndrome. We investigated clinical data in comparison to undetectable hs-cTnT. The study comprised of 682 patients (November 2010/September 2011) presenting at the emergency department with chest pain and normal hs-cTnT (<14 ng/L). The main endpoint was major adverse cardiac events (MACE: death, myocardial infarction, readmission for unstable angina or revascularization) at a 4-year median follow-up; secondary endpoint was 30-day MACE. A clinical score was built by assigning points according to hazard ratios of the independent predictive variables: 1 point (male and effort-related pain), and 2 points (recurrent pain and prior ischemic heart disease).The negative predictive values of the clinical score and undetectable hs-cTnT (<5 ng/L), were tested. A total of 72 (10.6%) patients suffered long-term MACE. The C-statistics of the clinical score for long-term (0.75) and 30-day (0.88) MACE were higher than with the TIMI risk (0.68, 0.77) or GRACE (0.50, 0.47) scores. Likewise, the negative predictive values of score= 0 (97.5%, 100%) and ≤1 point (95.9%, 100%) were higher than using undetectable hs-cTnT (91.9%, 98.1%). Both a clinical score of 0 and ≤1 classified better patients at risk of MACE (p=0.0001, log rank test) than hs-cTnT<5 ng/L (p=0.06). In conclusion, clinical data can guide decision making and perform at least equally well as undetectable hs-cTnT, in patients presenting at the emergency department with chest pain and normal hs-cTnT.