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BackTable / VI / Tool
HEART Score Calculator: Risk Stratification for Chest Pain in the ED
The HEART Score calculator is a widely used clinical tool designed to stratify patients presenting with chest pain based on their risk of experiencing major adverse cardiac events (MACE) within 6 weeks. Developed in the Netherlands in the late 2000s, the HEART Score was created to fill the gap between subjective clinical judgment and more invasive or costly cardiac testing. It helps emergency physicians and hospitalists make informed decisions regarding patient disposition by quantifying key elements of the presentation. By combining clinical and biochemical parameters, the HEART Score provides an objective framework to determine whether a patient can be safely discharged, requires observation, or needs advanced diagnostic evaluation. It also incorporates a qualitative assessment of symptoms and ECG findings alongside age, risk factors, and troponin levels. This approach has been validated in multiple cohorts and integrated into protocols for chest pain evaluation worldwide.
HEART Score Calculator
History
Based on clinician judgment of whether symptoms are:
EKG
(0) Normal EKG
(1) Non-specific repolarization abnormalities (e.g., due to LBBB, LVH, or digoxin effect) without clear ST deviation
(2) Significant ST segment deviation not explained by LBBB, LVH, or digoxin
Age
Risk Factors
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); atherosclerotic disease: prior MI, PCI/CABG, CVA/TIA, or peripheral arterial disease
Initial troponin
Use local, regular sensitivity troponin assays and corresponding cutoffs
Value 1
Value 2
Value 3
Clinical Components of the HEART Score
The acronym HEART stands for History, ECG, Age, Risk factors, and Troponin. Each of these five components is scored from 0 to 2:
• History: Based on clinician judgment of whether symptoms are non-specific (0), moderately suspicious (1), or highly suspicious (2).
• ECG: Normal (0), nonspecific repolarization abnormalities (1), or significant ST-depression (2).
• Age: <45 years (0), 45–64 years (1), ≥65 years (2).Risk Factors: None (0), 1–2 risk factors or known atherosclerotic disease (1), ≥3 risk factors (2).
• Troponin: Normal (0), 1–3× normal limit (1), >3× normal limit (2), adjusted for assay sensitivity.
The total score ranges from 0 to 10. This score correlates directly with the likelihood of MACE, making it a reliable metric for bedside decision-making in patients with undifferentiated chest pain.
Interpreting HEART Score Results
Interpretation of the HEART Score typically follows three risk categories:
• Low risk (0–3): Risk of MACE ranges from 0.9 - 1.7%. These patients are often suitable for discharge with outpatient follow-up.
• Intermediate risk (4–6): Risk of MACE ranges from 12 - 16.6%. These patients may benefit from observation, serial troponins, or non-invasive testing.
• High risk (7–10): Risk of MACE ranges from 50 - 65%. These patients often require cardiology consultation and may need invasive testing.
The HEART Score facilitates standardized communication and supports shared decision-making. In busy emergency settings, it helps avoid both under-triage and overutilization of hospital resources.
Limitations and Contextual Considerations
Despite its utility, the HEART Score is not universally applicable. It may be less predictive in patients with atypical symptoms, baseline ECG abnormalities, or chronic kidney disease, where troponin levels can be elevated independent of acute coronary syndrome. In these cases, reliance on HEART alone may lead to misclassification. Assay variability also impacts interpretation. High-sensitivity troponins improve early detection but may reduce specificity in low-risk populations. Additionally, the qualitative assessment of “History” introduces variability across providers. Clinicians should not use the HEART Score in isolation. It functions best when integrated with serial biomarkers, imaging, and clinical judgment, especially in populations with non-traditional risk profiles or equivocal presentations.
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References
[1] Backus, B. E., Six, A. J., Kelder, J. C., Bosschaert, M. A., Mast, E. G., Mosterd, A., ... & Doevendans, P. A. (2013). A prospective validation of the HEART score for chest pain patients at the emergency department. International Journal of Cardiology, 168(3), 2153–2158. https://doi.org/10.1016/j.ijcard.2013.01.255
[2] Mahler, S. A., Riley, R. F., Hiestand, B. C., Russell, G. B., Hoekstra, J. W., Lefebvre, C. W., & Miller, C. D. (2015). The HEART Pathway randomized trial: identifying emergency department patients with acute chest pain for early discharge. Circulation: Cardiovascular Quality and Outcomes, 8(2), 195–203. https://doi.org/10.1161/CIRCOUTCOMES.114.001384
[3] Poldervaart, J. M., Reitsma, J. B., Backus, B. E., Koffijberg, H., Ten Haaf, M. E., Appelman, Y., ... & Moons, K. G. M. (2017). Effect of using the HEART Score in patients with chest pain in the emergency department: a stepped-wedge, cluster randomized trial. Annals of Internal Medicine, 166(10), 689–697. https://doi.org/10.7326/M16-1600
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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