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    HEART Score for Major Cardiac Events

    Predicts 6-week risk of major adverse cardiac event.


    Use in patients ≥21 years old presenting with symptoms suggestive of ACS. Do not use if new ST-segment elevation ≥1 mm or other new EKG changes, hypotension, life expectancy less than 1 year, or noncardiac medical/surgical/psychiatric illness determined by the provider to require admission. See also the HEART Pathway for a validated clinical pathway using the HEART Score.

    When to Use
    Why Use

    Any ED patient with chest pain that the physician deems appropriate for an ACS workup.

    • Helps ED providers risk-stratify chest pain patients into low, moderate, and high-risk groups.
    • HEART is an acronym of its components: History, EKG, Age, Risk factors, and troponin. Each of these is scored with 0, 1 or 2 points.
    • Designed to risk stratify patients with undifferentiated chest pain, not those already diagnosed with ACS.
    • Identifies patients with higher risk of having a MACE (all-cause mortality, myocardial infarction, or coronary revascularization) within in the following 6 weeks. 
    • The user needs some experience taking a detailed chest pain history and reading EKGs to adequately apply these two components of the score.
    • Sometimes compared to TIMI Score for UA/NSTEMI and the GRACE ACS Risk Score (older ACS scores), but the latter two differ from the HEART in that they measure risk of death for patients with diagnosed ACS.
    • The HEART Score outperforms the TIMI Score for UA/NSTEMI, safely identifying more low-risk patients.

    Objectively risk-stratifies patients into low, moderate, and high-risk categories, helping guide management, leading to better resource utilization, shorter hospital and ED stays for low risk patients, and earlier interventions for moderate- and high-risk patients.


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    Scores 0-3: 0.9-1.7% risk of adverse cardiac event. In the HEART Score study, these patients were discharged (0.99% in the retrospective study, 1.7% in the prospective study)

    Scores 4-6: 12-16.6% risk of adverse cardiac event. In the HEART Score study, these patients were admitted to the hospital. (11.6% retrospective, 16.6% prospective)

    Scores ≥7: 50-65% risk of adverse cardiac event. In the HEART Score study, these patients were candidates for early invasive measures. (65.2% retrospective, 50.1% prospective)

    A MACE (Major Adverse Cardiac Event) was defined as all-cause mortality, myocardial infarction, or coronary revascularization.

    Critical Actions

    Do not use if new ST-segment elevation requiring immediate intervention or clinically unstable patients.


    Addition of the selected points:


    0 points

    1 point

    2 points


    Slightly suspicious

    Moderately suspicious

    Highly suspicious



    Non-specific repolarization disturbance2

    Significant ST deviation3

    Age (years)




    Risk factors4

    No known risk factors

    1–2 risk factors

    ≥3 risk factors or history of atherosclerotic disease

    Initial troponin5

    ≤normal limit

    1–3× normal limit

    >3× normal limit

    1. e.g. Retrosternal pain, pressure, radiation to jaw/left shoulder/arms, duration 5–15 min, initiated by exercise/cold/emotion, perspiration, nausea/vomiting, reaction on nitrates within mins, patient recognizes symptoms. Low risk features of chest pain include: well localized, sharp, non-exertional, no diaphoresis, no nausea or vomiting, and reproducible with palpation.
    2. LBBB, typical changes suggesting LVH, repolarization disorders suggesting digoxin, unchanged known repolarization disorders.
    3. Significant ST-segment deviation without LBBB, LVH, or digoxin.
    4. HTN, hypercholesterolemia, DM, obesity (BMI >30 kg/m²), smoking (current, or smoking cessation ≤3 mo), positive family history (parent or sibling with CVD before age 65).
    5. Use local assays and corresponding cutoffs.

    Facts & Figures

    Evidence Appraisal

    The HEART Score was originally developed by Backus et al (2008) in a cohort of 122 patients with chest pain in an emergency department setting. The study included any patients admitted to the emergency department due to chest pain irrespective of age, prehospital assumptions, and previous medical treatments. It excluded patients with chest pain and significant ST segment elevations. Endpoints in this study were acute myocardial infarction (AMI), percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), and death. HEART Scores of 0-3 points confer a risk of 2.5% for any endpoint and therefore was used to support discharge from the ED. Conversely, scores 4-6 points confer a risk of 20.3%, implying admission for clinical observation is necessary. ≥7 points has a risk of 72.7% and supports early invasive strategies.

    In a retrospective multicenter validation study also by Backus et al (2010), 880 patients presenting with chest pain were evaluated. The primary endpoints studied were the same as the original study. 158 patients (17.95%) reached the primary endpoint. Of the 303 patients with HEART Scores 0 to 3, three (0.99%) had a MACE. In 413 patients with scores 4 to 6, 48 cases (11.6%) resulted in a MACE, and in HEART Scores 7 to 10, MACE was identified in 107/164 cases (65.2%).

    Backus et al externally validated the HEART Score with a prospective multicenter study in 2013. The study evaluated 2,440 patients presenting with chest pain to 10 emergency departments in the Netherlands. The primary endpoint was the occurrence of any MACE within 6 weeks. The performance of the HEART Score was also compared to that of the TIMI Score for UA/NSTEMI and the GRACE ACS Risk Score. In the low risk group (score 0-3), 15/870 (1.7%) of patients were found to have a MACE. In patients with HEART scores 4-6, MACE was diagnosed in 183/1101 (16.6%). In patients with high HEART scores (values 7-10), MACE occurred in 50.1%. The c-statistic of the HEART score (0.83) was significantly higher than the c-statistic of TIMI (0.75) and GRACE (0.70) respectively (p <0.0001).

    Poldervaart et al (2017) studied the HEART Score in a stepped-wedge cluster randomized trial with the objective of measuring both outcomes and use of healthcare resources. Nine Dutch hospitals were included in the study and were instructed to start usual care when assessing patients with chest pain. Every six weeks, one hospital was randomly assigned to use the HEART Score to assess patients with chest pain. A total of 3,648 patients were included (1,827 receiving usual care and 1,821 receiving HEART care). The study found that the six-week MACE incidence while using the HEART Score was 1.3% lower than with usual care, but there were no statistically significant differences in early discharge, readmissions, recurrent emergency department visits, outpatient visits, or visits to general practitioners.

    Recent studies have compared the HEART Score head-to-head with other clinical decision rules with regards to their ability to safely identify low risk patients. A study by Poldervaart et al (2017) comparing the HEART Score to the TIMI and GRACE Scores showed that the HEART Score outperformed the others when identifying low risk patients, with only 0.8% incidence of MACE in the low risk group.

    In addition, Nieuwets et al (2016) compared the HEART Score with the TIMI Score, with regards to identifying low risk patients without compromising safety while also evaluating expected cost reduction. They found that the HEART Score identified more patients as low risk compared with the TIMI Score, which would have led to potential cost savings of €64,107 (~USD $76,000) by using the HEART Score cutoffs versus €14,670 (~USD $17,000) for TIMI.

    The HEART Pathway developed by Mahler et al (2015) combined the HEART Score with 0- and 3-hour cardiac troponin tests in a decision aid designed to identify ED patients safe for early discharge. The study found that the HEART Pathway decreased length of stay by 12 hours, decreased objective cardiac testing by 12%, and increased early discharges by 21%. No MACE were seen within 30 days in patients who were identified for early discharge. Of note, this study (and the original HEART Score studies) use regular sensitivity cardiac troponin.


    Other References

    Research PaperPoldervaart JM, Langedijk M, Backus BE, et al. Comparison of the GRACE, HEART and TIMI score to predict major adverse cardiac events in chest pain patients at the emergency department. Int J Cardiol. 2017;227:656-661.Research PaperNieuwets A, Poldervaart JM, Reitsma JB, et al. Medical consumption compared for TIMI and HEART score in chest pain patients at the emergency department: a retrospective cost analysis. BMJ Open. 2016;6(6):e010694.Research PaperPoldervaart JM, Reitsma JB, Backus BE, et al. Effect of Using the HEART Score in Patients With Chest Pain in the Emergency Department: A Stepped-Wedge, Cluster Randomized Trial. Ann Intern Med. 2017.Research PaperMahler SA, Riley RF, Hiestand BC, et al. The HEART Pathway randomized trial: identifying emergency department patients with acute chest pain for early discharge. Circ Cardiovasc Qual Outcomes. 2015;8(2):195-203.
    Dr. Barbra Backus

    From the Creator

    From Barbra Backus, MD, PhD, co-author of the HEART Score:

    Why did you develop the HEART Score for Major Cardiac Events? Was there a clinical experience that inspired you to create this tool for clinicians?
    The HEART score was created based on expert opinion through examination of many patients with chest pain. The structure of the five elements with a 0, +1, and +2 scoring system (analogous to the Apgar score) helps to translate a long history and examination of a patient with chest pain into a comprehensible score of 0 to 10.
    What pearls, pitfalls and/or tips do you have for users of the HEART Score for Major Cardiac Events? Are there cases in which it has been applied, interpreted, or used inappropriately?
    The great benefit of the HEART score is that it is applicable to all chest pain patients in the ED or ACS unit. A minor pitfall is that the user needs at least some experience taking a chest pain history and reading an ECG to interpret these two elements of the score.
    I had a few questions about definitions — was troponin “on admission” the initial troponin drawn in the ER upon arrival there? Also, how did you define AMI in patients with a troponin already >3x normal? Was it AMI if the troponin continued to trend up, if no obvious EKG changes were seen?
    In all our validation studies, we used the first troponin on arrival. With that single troponin value, the HEART Score has a NPV > 98%. A recent study by Mahler et. al. shows that HEART <3 with 2 sets of negative troponin has a NPV of > 99% for MACE. Of course, every decrease in risk of endpoints is desirable, but HEART with a single troponin is already a very reliable predictor of MACE/ACS.
    For the definition of AMI we used the ESC guidelines. When there was any doubt (i.e., small troponin rise or concurrent arrhythmia) we would send the case to the adjudication committee for a definite risk stratification of the endpoint.
    What recommendations do you have for health care providers once they have applied the HEART Score for Major Cardiac Events? Are there any adjustments or updates you would make to the score given recent changes in medicine?
    The score is relatively new, so there are no major adjustments to make yet. Perhaps after we finish our current studies, we will be able to show that a HEART score with high sensitivity troponin is as good or perhaps better than the original HEART Score.
    I do think that the HEART score is a very good and easy-to-use instrument for every doctor working on an ED or ACS unit. However, the HEART score is just a scoring system and every patient is different. When you have any doubt or uncanny feeling about your patient, follow this: “The HEART Score can never replace our clinical thinking and our gut feeling.”
    Any other comments? Any new research or papers on this topic in the pipeline? Any thoughts on comparisons to other risk scores (GRACE, etc)?
    We are about to finish our implementation study, looking at the benefits, cost-effectiveness and safety of implementing the HEART score to our ED. Within the year, we will also finish studies on the HEART score in conjunction with different sets of troponin, like HEART plus copeptin, FABP and inter-observer variability.
    Finally — any interest or thought about developing your data set into continuous variables in a best-of-fit regression model? We've had a few authors who have taken their point-based scores and turned their variables into continuous ones — allowing us on the site to provide a better outcome estimate for users. (I've also been told these are great for publication, too.)
    We did perform regression analysis on the HEART score. I hope the results will be published soon. I do think that a continuous scoring with corresponding risk could be helpful for many clinicians. For example, helping clinicians to figure out the risk a patient has for potential MACE/ACS with a HEART score of 4 or 6, instead of the groups 0-3, 4-6 and 7-10.

    About the Creator

    Barbra Backus, MD, PhD, worked as a junior cardiologist under Dr. Six prior to her work on the HEART Studies. After completing her PhD, she began a residency in Emergency Medicine at the Albert Schweitzer Hospital in Dordrecht in the Netherlands. Her main research focus is on risk stratification of ACS.

    To view Dr. Barbra Backus's publications, visit PubMed

    About the Creator
    Dr. Barbra Backus
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