Written and maintained by CASRAI Editorial Board
Last updated
The HEART score is a validated 0-to-10 point clinical decision rule designed to stratify patients presenting to the emergency department (ED) with undifferentiated chest pain according to their short-term risk (30 days to 6 weeks) of experiencing a Major Adverse Cardiac Event (MACE). Unlike coronary intensive care scores derived only from patients already diagnosed with acute coronary syndrome, the HEART score evaluates five routine bedside variables—History, ECG, Age, Risk factors, and Troponin—at initial ED presentation. This page describes clinical risk-stratification instruments and health informatics workflows for research and administrative reference; it is not medical advice.
Definition, Origin, and Clinical Scope
Formulated by A.J. Six, B.E. Backus, and J.C. Kelder in the Netherlands Heart Journal (2008; PMID 18665203) and prospectively validated across 10 hospitals in 2,440 patients in the International Journal of Cardiology (Backus et al., 2013; PMID 23465250), the HEART score was built specifically for the unselected emergency department chest pain population. Following initial triage prioritization via the Emergency Severity Index (ESI), patients without clear ST-segment elevation myocardial infarction (STEMI) require structured evaluation to distinguish benign non-cardiac chest pain from unstable angina or non-ST-elevation myocardial infarction (NSTEMI).
In both the 2013 multicenter validation cohort and the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Chest Pain Guideline (Gulati et al., Circulation, 2021; PMID 34709879), the composite primary endpoint of Major Adverse Cardiac Events (MACE) is defined over a 30-day or 6-week follow-up window as the occurrence of any of the following:
- Acute myocardial infarction (AMI)
- Percutaneous coronary intervention (PCI)
- Coronary artery bypass grafting (CABG)
- Coronary angiography revealing procedurally significant stenosis managed conservatively, or all-cause mortality / cardiac death
How It Works: The Five HEART Score Components and 0–10 Point Scale
In a standard HEART score calculator workflow, each of the five acronym domains receives 0, 1, or 2 points based on clinical criteria documented by Six et al. (2008) and Backus et al. (2013):
| Component | 0 Points | 1 Point | 2 Points |
|---|---|---|---|
| H — History (clinical anamnesis of chest pain characteristics, radiation, onset, diaphoresis, nausea, and relief factors) | Slightly suspicious (absence of specific ischemic features; atypical presentation) | Moderately suspicious (contains both suspicious and non-suspicious elements) | Highly suspicious (classic retrosternal pressure, radiation to jaw/left arm, exertional trigger, or relief with nitrates) |
| E — ECG (12-lead electrocardiogram interpretation) | Normal ECG according to Minnesota criteria | Repolarization abnormalities without significant ST-segment depression (or bundle branch block, pacemaker rhythm, LVH, or digoxin effect) | Significant ST-segment depression or elevation in the absence of bundle branch block, LVH, or digoxin use |
| A — Age (patient age at presentation) | < 45 years | 45 to 64 years | ≥ 65 years |
| R — Risk Factors (hypertension, hypercholesterolemia, diabetes mellitus, obesity [BMI > 30 kg/m²], current or recent [<90 days] smoking, positive family history of CAD before age 65) | No known atherosclerotic risk factors | 1 or 2 risk factors present | ≥ 3 risk factors present, OR documented prior history of atherosclerotic disease (prior MI, PCI, CABG, CVA/TIA, or peripheral arterial disease) |
| T — Troponin (cardiac troponin I or T relative to the local institutional 99th-percentile upper reference limit) | ≤ normal limit | 1 to 3× normal limit | > 3× normal limit |
HEART Score Risk Stratification Tiers (Backus et al., 2013 Validation)
Summing the five domain scores yields a total score from 0 to 10, which stratifies patients into three risk categories with validated 6-week MACE incidence rates from the 2,440-patient prospective multicenter study (Backus et al., 2013; PMID 23465250):
- Low Risk (HEART Score 0–3): Represented 36.4% of the validation cohort with a 6-week MACE incidence of 1.7%. In clinical decision pathways (particularly when paired with serial negative troponin testing), low-risk patients are candidates for early discharge from the emergency department without inpatient admission or urgent noninvasive stress testing.
- Intermediate Risk (HEART Score 4–6): Represented 46.1% of the cohort with a 6-week MACE incidence of 16.6%. Intermediate-risk patients typically warrant observation unit admission, serial biomarker monitoring, and noninvasive anatomical (coronary CT angiography) or functional cardiac imaging.
- High Risk (HEART Score 7–10): Represented 17.5% of the cohort with a 6-week MACE incidence of 50.1%. High-risk patients warrant cardiology consultation and evaluation for early invasive coronary strategies.
Types and Related Chest Pain / Cardiac Risk Scores
Clinical informaticists and cardiovascular researchers distinguish the original static HEART score from serial-troponin pathways and other cardiovascular risk instruments:
| Instrument | Target Population | Troponin Protocol | Primary Endpoint & Horizon | Discrimination / Clinical Role |
|---|---|---|---|---|
| Original HEART Score (Six et al., 2008; Backus et al., 2013) | Undifferentiated acute chest pain in the ED | Single baseline cardiac troponin at presentation | 6-week MACE (AMI, PCI, CABG, death) | C-statistic 0.83 in Backus et al. (2013); rapid bedside stratification |
| HEART Pathway (Mahler et al., 2015; PMID 25737484) | Undifferentiated acute chest pain in the ED | HEART score (0–3) PLUS serial troponin at 0 and 3 hours | 30-day MACE and early ED discharge rate | Reduces 30-day miss rate below 1% by catching early troponin risers who had a low baseline HEART score |
| TIMI Score (UA/NSTEMI) (Antman et al., 2000) | Confirmed unstable angina or NSTEMI cohorts | Binary cardiac marker elevation (0 or 1 point) | 14-day mortality, new/recurrent MI, or urgent revascularization | C-statistic 0.65 when applied to undifferentiated ED chest pain (Backus et al., 2013); designed for confirmed ACS |
| Killip Classification (Killip & Kimball, 1967) | Patients presenting with acute myocardial infarction | Not a score input (physical exam signs of heart failure) | In-hospital mortality from pump failure / cardiogenic shock | 4-class physical examination staging of left ventricular dysfunction after acute MI |
| ASCVD Risk Estimator / PREVENT | Outpatient primary prevention (asymptomatic adults) | None (lipids, blood pressure, smoking, diabetes, age) | 10-year and 30-year atherosclerotic cardiovascular disease risk | Long-term outpatient statin and antihypertensive therapy guidance; never used for acute ED chest pain |
Where It Matters for Clinical Informatics, Trials, and EHR Decision Support
In hospital quality operations and clinical research informatics, the HEART score and HEART Pathway are deployed as structured Electronic Health Record (EHR) Clinical Decision Support (CDS) interventions:
- SMART on FHIR and Embedded EHR Calculators: Rather than requiring clinicians to manually look up age, problem-list comorbidities (ICD-10 codes for hypertension, diabetes, hyperlipidemia, obesity, or prior CAD), and laboratory troponin values (mapped via LOINC codes for cardiac troponin I or T), EHR flowsheet calculators and integrated MDCalc SMART on FHIR apps auto-populate the Age, Risk factor, and Troponin fields while prompting the clinician to attest to the History and ECG domains.
- Inter-Rater Reliability of the “History” Domain: Because the History component (slightly, moderately, or highly suspicious) relies on subjective clinical synthesis, implementation studies and the HEART Pathway (Mahler et al., 2015) replace unstructured judgment with standardized objective symptom questions inside the EHR order set to improve inter-rater reproducibility across emergency physicians and advanced practice providers.
- High-Sensitivity Cardiac Troponin (hs-cTn) Calibration: As documented in the 2021 AHA/ACC Chest Pain Guideline (Gulati et al., 2021), modern emergency departments increasingly pair structured clinical decision pathways with fifth-generation high-sensitivity cardiac troponin (hs-cTnI or hs-cTnT) assays, enabling accelerated 0/1-hour or 0/2-hour rule-out algorithms alongside the HEART risk tier.
Common Misunderstandings in Clinical Practice and Research
- Misunderstanding 1: “A HEART score of 2 or 3 with a positive initial troponin is safe for discharge.” In the original sum-score arithmetic, a young patient (<45 years, 0 points) with no risk factors (0 points), a normal ECG (0 points), a slightly suspicious history (0 points), and a markedly elevated troponin (>3× normal limit, 2 points) mathematically totals a HEART score of 2. However, an acute troponin elevation above the 99th percentile indicates myocardial injury. The HEART Pathway (Mahler et al., 2015) and 2021 AHA/ACC guidelines explicitly require both a HEART score ≤ 3 AND negative serial troponin results at 0 and 3 hours (or validated hs-cTn deltas) before classifying a patient as low risk for early discharge.
- Misunderstanding 2: “Confusing the US/Dutch ED HEART Score with the European Society of Cardiology HeartScore.” In cardiovascular epidemiology, the European Society of Cardiology (ESC) operates an unrelated outpatient preventive cardiology tool named HeartScore (based on the SCORE2 10-year fatal and non-fatal CVD risk equations). Researchers extracting EHR data must verify whether “HEART score” refers to the 0–10 acute emergency department rule (Six/Backus) or the 10-year outpatient primary prevention calculator.
Frequently Asked Questions
What is heart score?
The HEART score is a validated 0-to-10 point clinical decision rule developed by Six, Backus, and Kelder (2008) to stratify patients presenting to the emergency department with undifferentiated chest pain according to their short-term risk of Major Adverse Cardiac Events (MACE). Its five acronym domains—History, Electrocardiogram (ECG), Age, Risk factors, and Troponin—are each scored 0, 1, or 2 points, categorizing patients into low-risk (0–3 points), intermediate-risk (4–6 points), and high-risk (7–10 points) tiers.
How is heart score used in clinical research and healthcare?
In emergency medicine and cardiovascular clinical trials, the HEART score and the serial-troponin HEART Pathway (Mahler et al., 2015) are embedded as Electronic Health Record (EHR) clinical decision support tools to standardize chest pain disposition, reduce unnecessary inpatient observation admissions, and define cohort eligibility or baseline risk strata in acute coronary syndrome (ACS) diagnostic studies.
Sources
- Six AJ, Backus BE, Kelder JC — “Chest pain in the emergency room: value of the HEART score,” Netherlands Heart Journal, 2008;16(6):191–196, PMID: 18665203 (https://pubmed.ncbi.nlm.nih.gov/18665203/).
- Backus BE, Six AJ, Kelder JC, et al. — “A prospective validation of the HEART score for chest pain patients at the emergency department,” International Journal of Cardiology, 2013;168(3):2153–2158, PMID: 23465250 (https://pubmed.ncbi.nlm.nih.gov/23465250/).
- Mahler SA, Riley RF, Hiestand BC, et al. — “The HEART Pathway randomized trial: identifying emergency department patients with acute chest pain for early discharge,” Circulation: Cardiovascular Quality and Outcomes, 2015;8(2):195–203, PMID: 25737484 (https://pubmed.ncbi.nlm.nih.gov/25737484/).
- Gulati 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(22):e368–e454, PMID: 34709879 (https://pubmed.ncbi.nlm.nih.gov/34709879/).
