About the HEART Score
The HEART Score is a validated clinical decision tool developed specifically for risk stratification of chest pain in the emergency department. It estimates the probability of a major adverse cardiac event (MACE) — defined as acute MI, PCI, CABG, or death — within 6 weeks of ED presentation.
The HEART Score was developed by Backus et al. in the Netherlands and published in 2010 (Netherlands Heart Journal) as a simple, clinician-friendly tool for emergency department chest pain risk stratification. Unlike the TIMI score — derived from trial patients with known ACS — HEART was developed specifically for undifferentiated ED chest pain, making it better calibrated for the typical ED population where most presentations turn out to be non-cardiac.
The score gained widespread adoption after the landmark HEART Pathway randomized controlled trial (Mahler et al., JAMA Intern Med 2015), which demonstrated that systematic use of the HEART Score reduced 30-day objective cardiac testing by 12.1% and accelerated ED discharge without increasing adverse events. The HEART Score is now included in the American College of Emergency Physicians (ACEP) clinical policy for chest pain evaluation and referenced in the ACC/AHA 2021 Chest Pain Guidelines.
The acronym stands for: History, ECG, Age, Risk factors, and Troponin. Each component is scored 0–2, yielding a total possible score of 0–10. The score is designed to be calculated at the bedside, typically using the first troponin result — serial troponins further refine risk in patients with intermediate scores.
How to Use the HEART Score
Follow these steps to calculate the HEART Score for a patient presenting with undifferentiated chest pain:
- H — History: Assess the quality of chest pain. Score 2 if highly typical (substernal pressure/crushing, radiation to jaw/arm, diaphoresis, exertional, nitrate-responsive). Score 1 if moderately suspicious (some typical features). Score 0 if mostly atypical (sharp, positional, pleuritic, reproducible on palpation).
- E — ECG: Review the 12-lead ECG. Score 2 for significant ST deviation or new T-wave inversions not explained by LBBB/LVH. Score 1 for non-specific repolarization changes, LBBB, LVH, early repolarization, or paced rhythm. Score 0 for a normal ECG.
- A — Age: Score 0 for age under 45, 1 for 45–64, 2 for age 65 or older.
- R — Risk Factors: Tally known cardiovascular risk factors (HTN, hypercholesterolemia, DM, obesity BMI >30, active/recent smoking, family history of CAD). Score 2 if ≥3 risk factors or known atherosclerotic disease (prior MI, PCI, CABG, stroke, PAD). Score 1 for 1–2 risk factors. Score 0 for none.
- T — Troponin: Use the first available troponin result. Score 0 if ≤normal (within lab reference range), 1 if 1–3× upper limit of normal, 2 if >3× upper limit of normal. Use your institution's assay-specific reference range.
- Sum the total (0–10) and interpret using the table below. Scores 0–3 are low risk; 4–6 intermediate; 7–10 high risk.
Score Interpretation
| HEART Score | Risk Category | 6-Week MACE | Recommendation |
|---|---|---|---|
| 0 – 3 | Low | ~1.7% | Consider early discharge / accelerated protocol |
| 4 – 6 | Moderate | ~16.6% | Admit for observation; serial troponins and monitoring |
| 7 – 10 | High | ~50.1% | Early invasive strategy; cardiology consultation |
Component Scoring Guide
| Component | 0 Points | 1 Point | 2 Points |
|---|---|---|---|
| History | Slightly suspicious | Moderately suspicious | Highly suspicious |
| ECG | Normal | Non-specific repolarization disturbance | Significant ST deviation |
| Age | <45 | 45–64 | ≥65 |
| Risk Factors | No known risk factors | 1–2 risk factors | ≥3 risk factors or atherosclerotic disease |
| Troponin | ≤Normal limit | 1–3× normal limit | >3× normal limit |
When to Use the HEART Score
The HEART Score applies to adult patients presenting to the ED with chest pain of possible cardiac origin. It is most useful for patients where the diagnosis is uncertain — i.e., not obvious STEMI, not clearly non-cardiac. Risk factors scored include: hypertension, hypercholesterolemia, diabetes mellitus, obesity (BMI >30), active or recent smoking, and family history of CAD.
HEART Score vs. TIMI Score
| Feature | HEART Score | TIMI Score |
|---|---|---|
| Derived from | Undifferentiated ED chest pain | ACS clinical trial patients (higher baseline risk) |
| Low-risk identification | Strong — 1.7% MACE at 6 weeks | Weaker — over-predicts risk in low-acuity patients |
| ED-specific validation | Yes — multiple prospective ED studies | Limited — derived outside ED context |
| Clinical history component | Yes — incorporates presentation quality | No |
| Guideline adoption | ACC/AHA 2021 Chest Pain Guidelines | Less prominent in current guidelines |
Limitations & Considerations
The HEART Score does not replace clinical judgment. It should not be used in isolation — patients with dynamic ECG changes, hemodynamic instability, or STEMI require immediate management irrespective of score.
- Subjectivity of History: The "H" component requires clinical gestalt and is the most subjective element. Interobserver variability is documented, particularly for moderately suspicious presentations. Less experienced clinicians may score this component less reliably.
- Troponin assay variability: Thresholds for 1× and 3× ULN differ between conventional and high-sensitivity assays, and between institutions. Always apply the institutional reference range — do not use an absolute ng/mL value.
- Not for STEMI: The HEART Score is irrelevant in the setting of obvious ST-elevation MI, which requires immediate cath lab activation regardless of score.
- Not validated in pediatric or obstetric populations: Validation studies enrolled adult ED patients. Do not apply to pediatric chest pain or pregnant patients.
- Post-procedure and post-cardiac surgery patients: Baseline troponin elevations (e.g., after cardioversion, ablation, or surgery) confound troponin scoring.
- Renal insufficiency: Patients with CKD often have chronically elevated troponins. Elevated troponin in this context does not carry the same prognostic weight as in patients with normal renal function.
- Not a standalone discharge tool: Even a HEART Score ≤3 does not guarantee the absence of ACS. Shared decision-making, patient-specific risk factors, and access to follow-up should all inform discharge decisions.
References
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. doi:10.1007/BF03086144
Backus BE, Six AJ, Kelder JC, et al. Chest pain in the emergency room: a multicenter validation of the HEART Score. Crit Pathw Cardiol. 2010;9(3):164–169.
Backus BE, Six AJ, Kelder JC, et al. A prospective validation of the HEART score for chest pain patients at the emergency department. Int J Cardiol. 2013;168(3):2153–2158. doi:10.1016/j.ijcard.2013.01.255
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. doi:10.1161/CIRCOUTCOMES.114.001384
Mahler SA, Stopyra JP, Apple FS, et al. Use of the HEART pathway with high sensitivity cardiac troponins. Am Heart J. 2017;193:30–38.
Kontos MC, de Lemos JA, Deitelzweig SB, et al. 2022 ACC Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department. J Am Coll Cardiol. 2022;80(20):1925–1960.