Validated for ED chest pain triage
Guidelines & Evidence
Verified
Last Review: 2026-07-17
When to Use
When to Use
Risk stratification of patients ≥18 years presenting to the Emergency Department with chest pain.
Assessing the probability of Major Adverse Cardiac Events (MACE) within 6 weeks.
Identifying low-risk patients suitable for early discharge without bedside observation or immediate provocative testing.
When NOT to Use
New ST-segment elevation (STEMI): These patients require immediate reperfusion.
Hemodynamic instability or obvious alternative life-threatening diagnosis (e.g., tension pneumothorax).
Patients with new, clearly ischemic ECG changes (ST-depression ≥1mm).
How it Works
Scoring Components
| H — History | Highly Suspicious (2), Moderately (1), Slightly (0) |
| E — ECG | ST-depression (2), Non-specific (1), Normal (0) |
| A — Age | ≥65 (2), 45-64 (1), <45 (0) |
| R — Risk Factors | ≥3 (2), 1-2 (1), 0 (0) |
| T — Troponin | ≥3x Limit (2), 1-3x Limit (1), ≤Limit (0) |
Interpretation & MACE Risk
| Score 0–3 | Low Risk (0.9–1.7% MACE) |
| Score 4–6 | Intermediate Risk (12–16.6% MACE) |
| Score 7–10 | High Risk (50–65% MACE) |
Clinical Pearls
The "History" Variable
History is the most subjective component but also one of the most predictive. "Highly suspicious" generally includes retrosternal pressure, radiation to arms/jaw, and diaphoresis. A score of "0" requires a non-ischemic explanation for the pain.
HEART vs. TIMI & GRACE
HEART was designed specifically for the undifferentiated ED chest pain population.
TIMI and GRACE were derived from patients already diagnosed with ACS, making them better for prognosis but less ideal for "rule-out" triage.
The HEART score is widely considered the superior rule-out tool in modern emergency medicine.
Next Steps
Management Recommendations
01
Score 0–3: Consider immediate discharge. Recent evidence suggests MACE risk is low enough for outpatient follow-up.
02
Score 4–6: Admission for observation, serial troponins, and potentially non-invasive testing (Stress test, CCTA).
03
Score 7–10: High probability of ACS. Early invasive strategy (Catheterization) often indicated.
Complementary Tools
HEART Pathway
TIMI (UA/NSTEMI)
GRACE Score
EDACS Score
Vancouver Chest Pain Rule
The Evidence
Primary Derivation
Chest pain in the emergency room: value of the HEART score.
Six AJ et al. • Neth Heart J.. 2008;n=122. Initial study showing that no patients with low HEART scores had a MACE.
Large Scale Validation
A prospective validation of the HEART score for chest pain patients at the emergency department.
Backus BE et al. • Int J Cardiol.. 2013;n=2,388. Confirmed the low MACE rate in those with scores <4.
Origins & History
Development Team
Created by Dr. Jacobus Six and colleagues in the Netherlands. It was designed to provide a simple, easy-to-remember mnemonic that combined clinical judgment with objective lab and ECG data.
Last Comprehensive Review: 2026-07-17