HEART Score for Major Cardiac Events
What is the short-term risk of a major adverse cardiac event in an adult with chest pain in the ED?
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About this tool
Five-element score (History, ECG, Age, Risk factors, Troponin) that stratifies undifferentiated emergency department chest pain into low, moderate and high risk of 6-week MACE.
Intended use
Adults presenting to the emergency department with symptoms suggestive of acute coronary syndrome.
Outcome
Major adverse cardiac events (death, MI, coronary revascularisation)
Time horizon
6 weeks
Derivation population
Adult ED patients with chest pain in Dutch hospitals (derivation 2008; multicentre validation 2013).
Do not use in
STEMI, obvious non-cardiac chest pain, haemodynamic instability.
Limitations
- History and ECG items are subjective, with moderate inter-rater agreement.
- Developed with conventional troponin; high-sensitivity assays require validated accelerated pathways.
- Not a substitute for serial troponin testing.
Clinical problems
Evidence
Evidence level
Strong evidence
Derived and externally validated in multiple cohorts (including prospective studies) and incorporated into major clinical guidelines. Methodology
Guideline status
Listed among clinical decision pathways in the 2021 AHA/ACC multi-society chest pain guideline.
Discrimination
Reported C-statistic 0.83 in the 2013 multicentre validation (vs 0.75 TIMI and 0.70 GRACE in the same cohort).
Geographic applicability
Validated in Europe, North America and Asia.
Validation studies
Unselected ED chest-pain patients, 10 Dutch hospitals
6-week MACE: low 1.7%, moderate 16.6%, high 50.1%; C-statistic 0.83.
References
- Original publicationSix AJ, Backus BE, Kelder JC. Chest pain in the emergency room: value of the HEART score. Neth Heart J 2008;16:191-196. Find on PubMed (opens in a new tab)
- Validation studyBackus BE, Six AJ, Kelder JC, et al. A prospective validation of the HEART score for chest pain patients at the emergency department. Int J Cardiol 2013;168:2153-2158. Find on PubMed (opens in a new tab)
- Validation studyMahler SA, Riley RF, Hiestand BC, et al. The HEART Pathway randomized trial. Circ Cardiovasc Qual Outcomes 2015;8:195-203. Find on PubMed (opens in a new tab)
- GuidelineGulati M, Levy PD, Mukherjee D, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain. Circulation 2021;144:e368-e454. Find on PubMed (opens in a new tab)
Version history
| Version | Formula | Effective | Reviewer | Changes |
|---|---|---|---|---|
| v1.0.0 | Six 2008 / Backus 2013 point allocation | 2026-10-03 | — | Initial implementation with reference test vectors. |
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Clinical decision support only. Interpret results in the context of the individual patient and current guidance; HumanPulse does not replace professional medical judgment.