We identified all patients with age 21 years and older, without a history of obstructive coronary artery disease, who presented to the emergency department with chest pain, and were admitted for cardiac observation followed by stress echocardiography during a 1-year period. The positive predictive value of stress echocardiography and cardiovascular outcomes were compared based on patients’ Diamond chest pain classification. In patients with typical chest pain, who accounted for 8.7% (44/503) of the total cohort, the positive predictive value of stress echocardiography was 75% compared with 0% for all other subgroups (P = 0.007). Six patients (14%) with typical chest pain went on to have coronary revascularization compared with 0% for all other subgroups (P < 0.001). No patient in any subgroup died or was readmitted with a myocardial infarction in 30 days. Applying the Diamond criteria could improve utilization of stress echocardiography for patients with low-risk chest pain in the emergency department.