HEART Score: Validated chest pain triage tool for Predicting Major Adverse Cardiac Events (MACE).
Guidelines & Evidence
Clinical Details
Section 1
When to Use
When to Use
Adult patients ≥ 18 years presenting with chest pain to Emergency or Internal Medicine
Stratify risk of 30-day MACE (death, MI, or revascularisation)
Guide decision between early discharge vs admission and invasive workup
Combine with serial troponins (at 0h and 2–3h) for optimal accuracy
HEART Score + Troponin Algorithm
HEART score alone is not sufficient. Always combine with two serial high-sensitivity troponin measurements. A HEART 0–3 + two negative hs-troponins = 30-day MACE risk < 2% → safe early discharge.
Section 2
Formula & Logic
Five Components (0–2 points each)
H — History: Ischaemic character of chest pain
E — ECG: ST deviation, LBBB, LVH, or repolarisation changes
A — Age: < 45 = 0, 45–64 = 1, ≥ 65 = 2
R — Risk factors: Known atherosclerosis scores 2; ≥ 3 risk factors = 2; 1–2 risk factors = 1
T — Troponin: ≤ normal = 0; 1–3× ULN = 1; > 3× ULN = 2
Risk Strata
01
Score 0–3 (Low): 1.7% MACE. Early discharge safe with negative troponins.
02
Score 4–6 (Moderate): 12% MACE. Observation, serial troponins, stress testing.
HEART is simpler than GRACE (no haemodynamics calculation required)
HEART is better calibrated for ED chest pain than TIMI (which was derived in ACS patients)
HEART score has been validated in > 50,000 patients across 20+ countries
Known ECG/Troponin Limitation
LBBB pattern (paced or Sgarbossa-negative) can score a false +2 on ECG domain. In LBBB patients, apply Sgarbossa or modified Sgarbossa criteria to assess for STEMI equivalence separately.
Section 4
Next Steps
Disposition Algorithm
01
HEART 0–3 + 2 negative hs-troponins: Discharge home. Outpatient cardiology/stress test within 72h.
02
HEART 4–6: Observation unit or admit. Stress test or coronary CTA. Cardiology consult.
Chest pain in the emergency room: value of the HEART score.
Six AJ et al. • Netherlands Heart Journal.. 2008;16(6):191–196.
Prospective Validation
A prospective validation of the HEART score for chest pain patients at the emergency department.
Backus BE et al. • International Journal of Cardiology.. 2013;168(3):2153–2158. 880 patients.
Section 6
Literature
HEART Score Development
Developed in the Netherlands by AJ Six and colleagues in 2008 as a simple bedside tool combining five clinical domains, each scored 0–2. Its elegant acronym (History, ECG, Age, Risk factors, Troponin) allows recall without a calculator. It has since become the dominant chest pain pathway tool in emergency medicine globally.
