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HEART Score

Chest Pain Risk Stratification for Major Adverse Cardiac Events

The HEART score stratifies patients with chest pain for risk of major adverse cardiac events (MACE) at 6 weeks. It combines five clinical parameters — History, ECG, Age, Risk Factors, and Troponin — each scored 0, 1, or 2. Total range: 0–10.

CardiologyEmergency MedicineChest PainACS
HEART Score Calculator

Select one option per category. Score updates automatically.

H History — Clinical Suspicion of ACS
E ECG
A Age
R Risk Factors
T Troponin (relative to institutional URL)
0
Low Risk
0.9–1.7%
MACE at 6 wks
Safe discharge
Disposition
Low risk: MACE rate <2%. Safe for discharge with outpatient follow-up.

Scoring Criteria Detail

Component0 pts1 pt2 pts
H HistorySlightly suspicious (atypical)Moderately suspiciousHighly suspicious (classic ACS features)
E ECGNormalNon-specific changes (LBBB, LVH, digoxin, early repolarisation)Significant ST deviation ≥1mm or T-wave inversion
A Age<45 years45–64 years≥65 years
R Risk factorsNone known1–2 risk factors≥3 risk factors OR known atherosclerotic disease
T Troponin≤1× URL1–3× URL>3× URL

Risk Stratification

ScoreRisk CategoryMACE at 6 WeeksRecommended Action
0–3Low Risk0.9–1.7%Safe discharge from ED with outpatient follow-up. No further in-hospital evaluation required.
4–6Moderate Risk12–16.6%Observation unit admission. Serial troponins (0h/3h/6h). Stress testing or early non-invasive imaging before discharge.
7–10High Risk50–65%Cardiology admission. Early invasive strategy (coronary angiography). Do not discharge without catheterisation.

MACE = major adverse cardiac event (myocardial infarction, PCI, CABG, death) at 6 weeks. Data from Six AJ et al. 2008 and Mahler SA et al. 2013 validation cohort.

Clinical Application

  • Troponin timing: The HEART score was originally designed using a single troponin at presentation. In practice, serial troponins (at 0 and 3 hours) improve sensitivity. The score should be re-calculated after the 3-hour troponin if the initial score is moderate (4–6).
  • HEART pathway: The HEART Pathway combines a HEART score ≤3 with a negative serial troponin protocol to safely discharge patients from the ED within 6 hours. This approach has been validated in prospective studies and endorsed by major cardiology societies.
  • ECG criterion: "Non-specific changes" is a broad category requiring clinical judgement. LBBB that is known to be old (chronic LBBB) scores 1; new LBBB in the context of chest pain scores 2 and warrants immediate cardiology review per Sgarbossa criteria.
  • Troponin URL: Always use your institution's specific upper reference limit (URL). High-sensitivity troponin assays have different URLs compared with conventional assays — apply the threshold appropriate to your laboratory.
  • Risk factor for R criterion: Known atherosclerotic disease (prior MI, revascularisation, stroke, or PAD) automatically scores 2 regardless of the number of traditional risk factors.
  • Limitations: The HEART score was derived in ED chest pain populations. It is not validated for patients with: STEMI (these should be treated immediately), known active PE, pericarditis, or aortic dissection as the primary diagnosis. Clinical context always supersedes the score.

References

  1. Six AJ, Backus BE, Kelder JC. Chest pain in the emergency room: value of the HEART score. Neth Heart J. 2008;16(6):191–196.
  2. Mahler SA, Hiestand BC, Goff DC Jr, Hoekstra JW, Miller CD. Can the HEART score safely reduce stress testing and cardiac imaging in patients at low risk for major adverse cardiac events? Crit Pathw Cardiol. 2011;10(3):128–133.
  3. Mahler SA, Riley RF, Hiestand BC, et al. The HEART Pathway randomized trial: identifying emergency department patients with acute chest pain for early discharge. Circ Cardiovasc Qual Outcomes. 2015;8(2):195–203.

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