Calc Function

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    • Subcategory of 'Diagnosis' designed to be very sensitiveRule Out
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    Patent Pending

    Marburg Heart Score (MHS)

    Rules out coronary artery disease in primary care patients with chest pain.
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    INSTRUCTIONS

    Do not use in an emergency setting.

    When to Use
    Pearls/Pitfalls
    Why Use
    • Patients ≥35 years old presenting with chest pain in a primary care setting.
    • Should not be used in patients with a readily apparent cause of chest pain (e.g. trauma, infection), clear anginal equivalent symptoms (e.g. jaw pain, dyspnea on exertion, arm pain), or if other testing (e.g. electrocardiography, lab testing) has suggested a clearly cardiac etiology.
    • Not to be used for a positive diagnosis of angina or CAD, but as a negative tool to help assess who is low-enough risk to not need further evaluation.
    • While scores ≤2 make unstable CAD highly unlikely (negative predictive value ~98%), scores ≥3 are only modestly predictive of CAD (positive predictive value ~23%).
    • Validated in patients 35 years and older.
    • Only ~1.5% of patients seen in primary care for chest pain have unstable coronary artery disease (CAD); the most common causes of chest pain in primary care are chest wall pain, gastrointestinal disease, and stable heart disease.
    • Helps determine which outpatients with chest pain are at sufficiently low risk of unstable CAD to allow for further follow-up, testing and management to be done on a non-urgent outpatient basis (scores ≤2); and who may be at high enough risk of CAD to warrant further testing on an urgent or inpatient basis (scores ≥3).
    No
    0
    Yes
    +1
    No
    0
    Yes
    +1
    No
    0
    Yes
    +1
    No
    +1
    Yes
    0
    No
    0
    Yes
    +1

    Result:

    Please fill out required fields.

    Next Steps
    Evidence
    Creator Insights

    Advice

    • When evaluating patients with chest pain in primary care, MHS ≤2 means the chest pain is highly unlikely to be due to unstable CAD (negative predictive value ~98%) and further outpatient evaluation is generally safe and appropriate.
    • A primary care patient with a MHS ≤2 generally does not need urgent evaluation of chest pain (unless there is clear evidence of clinical instability) and further evaluation, including chest x-ray and stress testing, may be done through non-urgent outpatient follow-up.
    • A primary care patient with a MHS ≥3 does not necessarily have unstable CAD, but since unstable CAD cannot be excluded, such patients generally warrant more urgent evaluation or inpatient admission.

    Management

    • For any primary care patient with chest pain, clinical stability can quickly be determined by evaluating the ABCs (airway, breathing, circulation).
    • A patient who shows no signs of respiratory distress and has appropriate vital signs is unlikely to be acutely unstable and can be further evaluated in the office with appropriately targeted history, physical examination, and testing.
    • If there is a readily apparent cause of chest pain other than CAD (e.g. trauma, infection), attention should be directed to these causes.
    • If there are clearly anginal equivalent symptoms (e.g. jaw pain, dyspnea on exertion, arm pain), or if there are ischemic changes on EKG, then the MHS does not apply and urgent inpatient admission is warranted.

    Critical Actions

    No decision rule should trump clinical gestalt, and any patient with chest pain who is clinically unstable (respiratory distress or abnormal vital signs) warrants urgent or emergency inpatient admission.

    Formula

    Addition of the selected points:

     

    No

    Yes

    Female ≥65 years or male ≥55 years

    0

    +1

    Known CAD, cerebrovascular disease, or peripheral vascular disease

    0

    +1

    Pain worse with exercise

    0

    +1

    Pain reproducible with palpation

    +1

    0

    Patient assumes pain is cardiac

    0

    +1

    Facts & Figures

    Interpretation:

    Marburg Heart Score

    CAD risk

    Recommendation

    0–2

    3%

    Outpatient evaluation as needed

    ≥3

    23%

    Consider urgent evaluation or inpatient admission

     

    Evidence Appraisal

    • The MHS was originally derived by Bösner et al from a cross-sectional analysis of data from 1,249 consecutive patients seen in primary care practices for chest pain, and validated against data on similar patients from a separate, prospective primary care study; a score of 3 or more had a sensitivity of 87.1% and a specificity of 80.8% for CAD.
    • A subsequent validation study among 844 men and women age 35 or older seen in primary care for chest pain found a score of 3 or greater was 89% sensitive and 63% specific for CAD, with a negative predictive value of 97% and a positive predictive value of 23%.
    • A comparative study with 56 general practitioners (GPs) evaluating 832 primary care patients with chest pain found that using the MHS as a triage improved GPs clinical accuracy.

    Literature

    Dr. Stefan Bösner

    About the Creator

    Stefan Bösner, MD, MPH, is a professor of general practice and family medicine at Philipps University of Marburg in Marburg, Germany. He is active clinically as a general practitioner. Dr. Bösner has published multiple studies on coronary artery disease, specifically chest pain in primary care and medical decision making.

    To view Dr. Stefan Bösner's publications, visit PubMed

    Content Contributors
    • William Cayley Jr, MD, MDiv
    About the Creator
    Dr. Stefan Bösner
    Content Contributors
    • William Cayley Jr, MD, MDiv