What is the HEART (History, Electrocardiogram, Age, Risk factors, Troponin) score used for in making clinical decisions for patients with acute chest pain?

The HEART Score for Clinical Decision-Making in Chest Pain

The HEART score is a clinical risk tool for rapid stratification of patients with chest pain that predicts all-cause mortality, myocardial infarction, or coronary revascularization, allowing clinicians to safely identify low-risk patients who can be discharged without further testing. 1

Components of the HEART Score

The HEART score consists of five components, each scored from 0-2 points, for a maximum total of 10 points:

1. History 1

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

2. ECG 1

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

3. Age 1

   • 65 years: 2 points

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

4. Risk factors 1

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

5. Troponin 1

   • 3× normal limit: 2 points

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

Risk Stratification and Clinical Decision-Making

The HEART score categorizes patients into three risk groups: 1

• Low risk (0-3 points): <1% risk of major adverse cardiac events (MACE) within 30 days, supporting immediate discharge 2, 3
• Intermediate risk (4-6 points): ~11.6% risk of MACE, indicating need for admission and clinical observation 2, 4
• High risk (≥7 points): ~65.2% risk of MACE, supporting early invasive strategies 2, 3

Clinical Implementation

The HEART score has been validated in multiple settings and offers several advantages:

• Facilitates accurate diagnostic and therapeutic decisions without radiation or invasive procedures 2
• Provides higher sensitivity (94.1%) and negative predictive value (98.1%) for 30-day MACE compared to other risk scores 5
• Can be incorporated into chest pain pathways to safely decrease hospital admissions (21% relative increase in discharges of low-risk patients) 6
• Helps emergency physicians achieve the acceptable miss rate of 1-2% for 30-day MACE recommended by the American College of Emergency Physicians 1

Integration with Other Assessment Tools

• The HEART score can be used alongside high-sensitivity troponin testing in accelerated diagnostic protocols (ADPs) 1
• Serial high-sensitivity troponin measurements at 0 and 1 hour, 0 and 2 hours, or 0 and 3 hours are recommended by the American Heart Association for risk stratification 7
• For intermediate-risk patients with known CAD, stress imaging may be reasonable, while invasive coronary angiography is recommended for high-risk patients 7

Potential Pitfalls

• Overreliance on a single parameter while ignoring clinical context should be avoided 7
• Small fluctuations in troponin levels may reflect assay imprecision rather than acute cardiac injury 7
• The HEART score may be less accurate in very early presenters where troponin elevation hasn't yet occurred 1
• Serial ECG changes are crucial when the initial ECG is nondiagnostic 7

The HEART score has replaced older risk stratification tools like TIMI and GRACE scores specifically for evaluation of patients with chest pain in the emergency department setting 1.