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Background: The High-STEACS (High-Sensitivity Troponin in the Evaluation of Patients With Acute Coronary Syndrome) pathway risk stratifies emergency department patients with possible acute coronary syndrome. This study aims to determine if the High-STEACS hs-cTnT (high-sensitivity cardiac troponin T) pathway can achieve the ≥99% negative predictive value (NPV) safety threshold for 30-day cardiac death or myocardial infarction (CDMI) in a multisite US cohort of patients with and without known coronary artery disease (CAD)., Methods: A secondary analysis of the STOP-CP (High-Sensitivity Cardiac Troponin T [Gen 5 STAT Assay] to Optimize Chest Pain Risk Stratification) cohort, which enrolled adult emergency department patients with possible acute coronary syndrome at 8 US sites (January 25, 2017-September 6, 2018). Participants were classified into outpatient and admission dispositions using the High-STEACS hs-cTnT pathway. Known CAD was defined as prior MI, coronary revascularization, or ≥70% coronary stenosis. Outcomes included 30-day CDMI and efficacy, defined as the proportion identified for outpatient disposition. NPVs and negative likelihood ratios for 30-day CDMI were calculated. NPVs were compared between CAD subgroups using a Fisher exact test., Results: Among 1351 patients, 53.2% (719/1351) were male, 31.4% (424/1351) had known CAD, and the mean age was 57.4±12.8 years. At 30 days, CDMI occurred in 13.8% (187/1351). High-STEACS classified 63.4% (857/1351) to outpatient disposition, of which 2.0% (17/857) had 30-day CDMI, corresponding to an NPV of 98.0% (95% CI, 96.8-98.8) and negative likelihood ratio of 0.13 (95% CI, 0.08-0.20). In patients with CAD, 46.9% (199/424) were classified to outpatient disposition, of which 4.0% (8/199) had 30-day CDMI. Among patients without CAD, 71.0% (658/927) were classified to outpatient disposition with 1.4% (9/658) having 30-day CDMI. The NPV for 30-day CDMI was 96.0% (95% CI, 92.2-98.2) in patients with CAD versus 98.6% (95% CI, 97.4-99.4) among patients without CAD ( P =0.04). The negative likelihood ratio for 30-day CDMI among patients with CAD was 0.16 (95% CI, 0.08-0.31) and 0.12 (95% CI, 0.06-0.22) among patients without CAD., Conclusions: The High-STEACS hs-cTnT pathway had high efficacy but was unable to achieve the ≥99% NPV safety threshold for 30-day CDMI., Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02984436., Competing Interests: Dr Ashburn receives funding from the National Heart, Lung, and Blood Institute (NHLBI; K23HL169929), Agency for Healthcare Quality and Research, Health Resources and Services Administration (R01HS029017), and the Emergency Medicine Foundation. Dr Snavely receives funding from NHLBI (K23HL169929), Abbott, HRSA (1H2ARH399760100), AHRQ (R01HS029017 and R21HS029234), and the Emergency Medicine Foundation. Dr Supples receives funding from the National Institutes of Health (NIH; UL1TR001420), AHRQ (R01HS029017), and the National Foundation of Emergency Medicine. Dr Mahler receives funding/support from Roche Diagnostics, Abbott Laboratories, QuidelOrtho, Siemens, Grifols, Pathfast, Beckman Coulter, Genetesis, Cytovale, National Foundation of Emergency Medicine, BlueJay Diagnostics, Duke Endowment, the Emergency Medicine Foundation, Brainbox, HRSA (1H2ARH399760100), and AHRQ (R01HS029017 and R21HS029234). He is a consultant for Roche, QuidelOrtho, Abbott, Siemens, Inflammatix, and Radiometer and is the Chief Medical Officer for Impathiq, Inc. Dr Allen receives research funding/support from Roche Diagnostics, Siemens, and Beckman Coulter. He is a consultant for Roche Diagnostics, Beckman Coulter, and Abbott. Dr Mumma has research support from the NIH (5K08HL130546) and Roche Diagnostics. Dr Wilkerson received research funding from Regeneron Pharmaceuticals, Inc, Lilly USA, LLC, BioAge Labs, Inc, Roche Diagnostics, Global Blood Therapeutics, Inc, Novartis Pharmaceuticals, Egetis Therapeutics AB, Endpoint Health, Inc, Blade Therapeutics, Janssen R&D LLC, ProvePharma, the National Foundation of Emergency Medicine, and Pfizer, Inc. He has received research funding from CoapTech, LLC through an NIH/National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) grant (R44DK115325). He has received research support in the form of equipment and supplies from Cepheid and Eldon Biologicals A/s. He is an uncompensated advisor to CSL Behring. Dr Christenson is a consultant for and receives funding/support from Roche Diagnostics, Siemens Healthineers, Beckman Coulter Diagnostics, Becton Dickinson and Co, Quidel Corp, and Sphingotec GMBH. The other authors report no conflicts.