Cardiology
HEART Score
Risk of major adverse cardiac event in chest pain.
Education and reference only. Not a substitute for clinical judgement, local policy or product labelling. Always verify before clinical use. Values are calculated in your browser and never stored.
Background
The HEART score risk-stratifies adults presenting with chest pain in the emergency department, estimating the 6-week risk of a major adverse cardiac event (MACE) — death, myocardial infarction or urgent revascularisation. It was designed specifically for undifferentiated chest pain rather than for confirmed acute coronary syndrome. The name is an acronym for its five components, each scored 0, 1 or 2: History, ECG, Age, Risk factors and Troponin. The total ranges from 0 to 10.
Interpreting the result
A score of 0–3 is low risk, with a MACE rate of only a few per cent, and these patients can often be discharged with safety-netting. A score of 4–6 is moderate risk and usually warrants admission or observation with serial troponin testing. A score of 7–10 is high risk and should prompt an early invasive strategy and cardiology involvement. The History and ECG elements involve clinical judgement, which is why HEART should be applied by, or in discussion with, an experienced clinician.
Advice
Score 0–3 ≈ low MACE risk (often dischargeable with safety-netting); 4–6 admit for observation; 7–10 high risk. Use with local chest-pain pathways and serial troponin.
Worked example
A 55-year-old with moderately suspicious history (1), non-specific repolarisation changes on ECG (1), age 45–64 (1), two risk factors (1) and an initial troponin at the upper normal limit (0) scores 4. This places them in the moderate-risk band, so they are observed with a repeat troponin rather than discharged.
Pearls / pitfalls
- It estimates risk in undifferentiated chest pain — it does not diagnose acute coronary syndrome and should not override an evolving clinical picture.
- The History and ECG components are subjective; inconsistent scoring between clinicians is the commonest source of error.
- A single low score is safest when paired with serial high-sensitivity troponin (the HEART Pathway), not on a single troponin alone.
- Always apply local chest-pain protocols; the score supports disposition but does not replace clinical judgement or safety-netting.
Evidence & validation
Derived by Six and colleagues and validated in multiple international cohorts, including the HEART Pathway studies that combined the score with serial troponin to safely discharge low-risk patients. It is widely incorporated into emergency-department chest-pain pathways.
Frequently asked questions
What HEART score allows discharge?
A score of 0–3 is low risk and can often be discharged with safety-netting, ideally after serial troponin testing as part of a local chest-pain pathway. A higher score warrants observation or admission.
Is HEART better than other chest-pain scores?
HEART was designed for undifferentiated chest pain and performs well at identifying low-risk patients, often better than scores designed for confirmed ACS such as TIMI or GRACE in this setting. Local pathways should guide which tool is used.
Does a low HEART score rule out a heart attack?
No score completely excludes a cardiac event. A low score combined with serial troponin makes a major adverse cardiac event unlikely, but ongoing or worsening symptoms still require reassessment.
What counts as a risk factor?
Risk factors include hypertension, hypercholesterolaemia, diabetes, smoking, a family history of premature coronary disease and obesity. Known atherosclerotic disease scores the maximum two points on this component.
Can HEART be used for any chest pain?
It is intended for adults with suspected cardiac chest pain in the emergency setting. It is not validated for clearly non-cardiac causes or for patients with ST-elevation myocardial infarction, who need immediate treatment.
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.
- 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.
About the creator
Six AJ, Backus BE et al.
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