How do you calculate the HEART score for a 68-year-old man presenting to the emergency department with worsening chest pain for one week and a history of multiple myeloma?

Calculating the HEART Score for a 68-Year-Old with Worsening Chest Pain and Multiple Myeloma

The HEART score is calculated by assigning 0-2 points to each of five components (History, ECG, Age, Risk factors, Troponin), with a maximum total of 10 points, and this patient likely scores at least 6-8 points placing him in intermediate-to-high risk requiring admission and cardiology evaluation. 1

HEART Score Components and Point Assignment

History Component (0-2 points)

• 2 points: Highly suspicious presentation—chest pain worsening over one week with exertional pattern or anginal characteristics 2, 3
• 1 point: Moderately suspicious—chest pain with some atypical features 2
• 0 points: Slightly suspicious—clearly non-cardiac chest pain 2

For this patient: The one-week duration with worsening pattern raises concern for unstable angina or progressive ischemia, likely scoring 1-2 points depending on specific characteristics (exertional vs rest, radiation pattern, associated symptoms) 2, 4

ECG Component (0-2 points)

• 2 points: Significant ST-segment deviation (≥0.5 mm horizontal/downsloping ST depression in ≥2 contiguous leads, ST elevation, T-wave inversion, or LBBB) 1
• 1 point: Nonspecific repolarization abnormalities (non-specific T-wave changes, left axis deviation, prolonged QTc) 4
• 0 points: Completely normal ECG 2

For this patient: Obtain a 12-lead ECG immediately; score based on findings above 1, 2

Age Component (0-2 points)

• 2 points: Age ≥65 years 2, 3
• 1 point: Age 45-64 years 2
• 0 points: Age <45 years 2

For this patient: At 68 years old, he receives 2 points 2, 3

Risk Factors Component (0-2 points)

Count the following traditional cardiovascular risk factors:

• Hypertension
• Hyperlipidemia
• Diabetes mellitus
• Current smoking
• Family history of premature CAD
• Obesity

Scoring:

• 2 points: ≥3 risk factors or known coronary artery disease 2, 3
• 1 point: 1-2 risk factors 2
• 0 points: No risk factors 2

For this patient: Multiple myeloma itself is not a traditional cardiac risk factor, but assess for the standard risk factors listed above 2. Important caveat: Multiple myeloma patients may have chronic kidney disease, anemia, and hyperviscosity that can contribute to cardiac stress and troponin elevation 5

Troponin Component (0-2 points)

• 2 points: Troponin >3× the 99th percentile upper reference limit (URL) 2, 3
• 1 point: Troponin 1-3× the 99th percentile URL 2, 3
• 0 points: Troponin ≤99th percentile URL 2, 3

For this patient: Obtain initial troponin immediately; if elevated, obtain serial measurements at 3-6 hours to assess for rising pattern (acute injury) versus stable elevation (chronic injury) 1, 5

Risk Stratification Based on Total Score

Low Risk (HEART Score 0-3)

• <2% risk of major adverse cardiac events (MACE) at 30 days 2, 3, 6
• Safe for immediate discharge with outpatient follow-up 2, 3

Intermediate Risk (HEART Score 4-6)

• 11.6-20.3% risk of MACE 3, 6
• Requires admission for observation, serial troponins at 3-6 hours, and risk stratification with stress testing or coronary CT angiography 1

High Risk (HEART Score ≥7)

• 52-72.7% risk of MACE 4, 3, 6
• Immediate hospital admission with cardiology consultation and likely cardiac catheterization 4

Critical Pitfalls in Multiple Myeloma Patients

Troponin interpretation requires extra caution: Multiple myeloma patients frequently have chronic troponin elevation due to:

• Renal dysfunction (light chain deposition, amyloidosis) 5
• Anemia causing demand ischemia 5
• Cardiotoxicity from chemotherapy agents 5

Do not dismiss elevated troponin as "chronic" without serial measurements showing stable values and correlation with prior levels 1, 5. A rising pattern indicates acute myocardial injury requiring aggressive management 5, 4.

Recommended Approach for This Patient

1. Obtain immediate 12-lead ECG looking specifically for ST-segment changes, T-wave abnormalities, or conduction abnormalities 1

2. Draw initial high-sensitivity troponin and compare to any prior values if available 1

3. Calculate preliminary HEART score using available data 1

4. If HEART score ≥4: Admit for observation with serial troponins at 3-6 hours 1

5. If HEART score ≥7: Immediate cardiology consultation for likely invasive strategy 4, 3

6. If troponin elevated: Distinguish acute versus chronic elevation by assessing for rising/falling pattern and clinical context 1, 5

The combination of age ≥65 years (2 points), worsening chest pain over one week (likely 1-2 points), and potential for elevated troponin in multiple myeloma patients makes this patient at minimum intermediate risk, requiring admission and serial cardiac biomarkers 2, 4, 3.