When screening for acute myocardial infarction (AMI), troponin levels below the 99th percentile, including those below the limit of detection (LOD), are considered normal. We hypothesized that a low-risk HEART Score (0–3) or ACS Pretest Probability Assessment <2% plus a single troponin below the LOD would rule out both AMI and 30-day major adverse cardiac events (MACE). We studied all patients who presented to a single academic ED and received a troponin I (Siemens Ultra Troponin I) from 9/1/13 to 11/13/13 (n=888). Demographic and clinical data were abstracted from the electronic medical record. Primary outcome was a final encounter diagnosis of MI. Secondary outcome was 30-day MACE, defined as composite of MI, revascularization, or death from a cardiac or uncertain etiology. Sensitivities of low-risk HEART score and ACS Pretest Probability <2% alone were 98% (95%CI 89–100%) and 96% (95%CI 86–100%) for AMI and 94% (95%CI 86–98%) and 95% (95%CI 88–99%), respectively, for 30-day MACE. When combined with troponin below the LOD, sensitivity for AMI was 100% (95%CI 93–100%; difference 2%, 95%CI −2% to 6%) for low-risk HEART Score and 100% (95%CI 93–100%; difference 4%, 95% CI −1.5 to 10%) for ACS Pretest Probability <2%. When combined with troponin below the LOD, sensitivity for 30-day MACE was 100% (95%CI 95–100%; difference 6%; 95%CI 1–12%) for low-risk HEART Score and 100% (95%CI 95–100%; difference 5%; 95%CI 0.2–10%) for ACS Pretest Probability <2%. Addition of a single troponin below the LOD to these scores improves sensitivity for 30-day MACE.