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Why the HEART Score is Used in Low Risk Chest Pain

January 14, 2017

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On the Shoulders of Giants

Every beat of my HEART…score
This was a prospective multicenter validation study of the HEART score to stratify which patients were very low risk for major adverse cardiac events (MACE).  A score of 0-3 was associated with MACE in 1.7%.  Scores of 4-6 were associated with MACE in 16.6%.

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Patients with a HEART score of 0-3 were very low risk for MACE and may be considered safe for early ED discharge.  REBEL EM did an excellent review of this study.  And if you prefer audio, the inimitable Captain Cortex, Stuart Swadron, and Billy Mallon give their take on it…worth a listen!


Int J Cardiol. 2013 Oct 3;168(3):2153-8. doi: 10.1016/j.ijcard.2013.01.255. Epub 2013 Mar 7.

A prospective validation of the HEART score for chest pain patients at the emergency department.

Backus BE1, Six AJ, Kelder JC, Bosschaert MA, Mast EG, Mosterd A, Veldkamp RF, Wardeh AJ, Tio R, Braam R, Monnink SH, van Tooren R, Mast TP, van den Akker F, Cramer MJ, Poldervaart JM, Hoes AW, Doevendans PA.

Author information:

1Department of Cardiology, University Medical Center, Utrecht, The Netherlands; Department of Emergency Medicine, Albert Schweitzer Hospital, Dordrecht, The Netherlands. Electronic address: backus@heartscore.nl.



The focus of the diagnostic process in chest pain patients at the emergency department is to identify both low and high risk patients for an acute coronary syndrome (ACS). The HEART score was designed to facilitate this process. This study is a prospective validation of the HEART score.


A total of 2440 unselected patients presented with chest pain at the cardiac emergency department of ten participating hospitals in The Netherlands. The HEART score was assessed as soon as the first lab results and ECG were obtained. Primary endpoint was the occurrence of major adverse cardiac events (MACE) within 6 weeks. Secondary endpoints were (i) the occurrence of AMI and death, (ii) ACS and (iii) the performance of a coronary angiogram. The performance of the HEART score was compared with the TIMI and GRACE scores.


Low HEART scores (values 0-3) were calculated in 36.4% of the patients. MACE occurred in 1.7%. In patients with HEART scores 4-6, MACE was diagnosed in 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) is significantly higher than the c-statistic of TIMI (0.75)and GRACE (0.70) respectively (p<0.0001).


The HEART score provides the clinician with a quick and reliable predictor of outcome, without computer-required calculating. Low HEART scores (0-3), exclude short-term MACE with >98% certainty. In these patients one might consider reserved policies. In patients with high HEART scores (7-10) the high risk of MACE may indicate more aggressive policies.

Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

PMID: 23465250 [PubMed – indexed for MEDLINE]