What is the role of the HEART (History, Electrocardiogram, Age, Risk factors, Troponin) score in assessing and managing patients with chest pain?

Role of the HEART Score in Assessing and Managing Chest Pain

The HEART score is the most accurate risk stratification tool for evaluating patients with chest pain in the emergency department, allowing clinicians to safely identify low-risk patients for early discharge while appropriately triaging intermediate and high-risk patients for further evaluation and management. 1

What is the HEART Score?

The HEART score is a clinical decision pathway (CDP) specifically designed for evaluating patients with chest pain in the emergency department. It consists of five components, each scored from 0-2 points:

1. History (0-2 points)

   • Highly suspicious: 2 points
   • Moderately suspicious: 1 point
   • Slightly suspicious: 0 points

2. ECG (0-2 points)

   • Significant ST-segment depression: 2 points
   • Nonspecific abnormalities: 1 point
   • Normal: 0 points

3. Age (0-2 points)

   • 65 years: 2 points

   • 45-65 years: 1 point
   • <45 years: 0 points

4. Risk factors (0-2 points)

   • ≥3 risk factors: 2 points
   • 1-2 risk factors: 1 point
   • No risk factors: 0 points

5. Troponin (0-2 points)

   • 3× normal limit: 2 points

   • 1-3× normal limit: 1 point
   • ≤ Normal limit: 0 points

Total score ranges from 0-10 points 1, 2

Risk Stratification Using HEART Score

The HEART score stratifies patients into three risk categories:

1. Low Risk (0-3 points)

   • <1% risk of 30-day major adverse cardiac events (MACE)
   • Safe for early discharge without extensive cardiac workup
   • 0.99% risk of MACE in validation studies 2, 3

2. Intermediate Risk (4-6 points)

   • ~11.6% risk of MACE
   • Requires observation and further cardiac evaluation 2

3. High Risk (7-10 points)

   • ~65.2% risk of MACE
   • Requires admission and consideration for early invasive strategy 2, 4

Clinical Application of the HEART Score

For Low-Risk Patients (HEART score 0-3):

• Can be safely discharged from the emergency department
• NPV >99% for 30-day MACE
• Reduces unnecessary admissions and testing
• Sensitivity of 95.9% for MACE 3

For Intermediate-Risk Patients (HEART score 4-6):

• Observation or admission is recommended
• Serial troponin measurements
• Consider non-invasive cardiac testing (stress testing or imaging)
• Higher risk of MACE (20.3%) 4

For High-Risk Patients (HEART score 7-10):

• Admission is mandatory
• Early invasive strategy often warranted
• High specificity (95%) for MACE 3
• Risk of MACE up to 72.7% 4

The HEART Pathway

The HEART Pathway is an enhanced version that combines the HEART score with serial troponin measurements to improve diagnostic accuracy:

1. First, exclude patients with ischemic ECG changes or STEMI
2. Calculate HEART score
3. For scores 0-3: Obtain serial troponins
   • If negative (<99th percentile): Safe for discharge
   • If positive (≥99th percentile): Cardiology consultation
4. For scores ≥4: Obtain initial troponin
   • Observation or admission regardless of result
   • Consider stress testing or angiography 1

Advantages of the HEART Score

• Specifically designed for chest pain evaluation in emergency settings
• Superior to older risk scores like TIMI and GRACE
• HEART score ≥4 has 95% sensitivity for mortality and 97.5% for MI 3
• Validated in multiple studies with consistent results
• Does not require radiation or invasive procedures
• Quick and easy to calculate at bedside 2

Limitations and Caveats

• Subjective nature of the history component may affect reliability
• Patients with troponin elevations or acute ischemic ECGs can still have low-risk scores
• May have variable performance in different populations
• Should be used in conjunction with clinical judgment
• Not intended for patients with known STEMI 1, 3

Comparison to Other Risk Scores

The HEART score outperforms traditional risk scores:

• More accurate than TIMI score (sensitivity 87.8% vs 95.9% for HEART)
• Better at identifying truly low-risk patients than GRACE score
• Designed specifically for undifferentiated chest pain in ED settings
• Identifies more patients as low-risk compared to other scores 1, 3

The HEART score has become the preferred risk stratification tool for chest pain evaluation, replacing older tools like TIMI and GRACE, and should be routinely implemented in clinical practice to guide disposition decisions and improve resource utilization while maintaining patient safety.