HEART Score
6-week MACE risk in chest pain
- Derived and validated in the Netherlands
Sources last checked: 2026-10-13
HEART Score
6-week MACE risk in chest pain
Not for patients with ST-elevation or haemodynamic instability. Band risks come from a cohort using conventional troponin; high-sensitivity troponin pathways use their own local thresholds.
Interpretation
| 0–3 — low | 1.7 % MACE at 6 weeks in the prospective validation (Backus 2013); the HEART authors regard early discharge as reasonable in this group. |
|---|---|
| 4–6 — moderate | 16.6 % MACE (Backus 2013); the HEART authors describe admission for observation and further testing in this group. |
| 7–10 — high | 50.1 % MACE (Backus 2013); the HEART authors describe an early invasive strategy as an option in this group. |
What is the HEART Score?
The HEART score stratifies adults with chest pain in the emergency department by their risk of a major adverse cardiac event (MACE) within six weeks. It was developed in the Netherlands by Six, Backus and Kelder (2008) and scores five elements — History, ECG, Age, Risk factors and Troponin — with 0 to 2 points each. In the prospective Dutch validation (2,440 patients), MACE occurred in 1.7 %, 16.6 % and 50.1 % of patients with scores 0–3, 4–6 and 7–10.
When to use it
- Adults presenting with undifferentiated chest pain suspicious of acute coronary syndrome, once the first ECG and troponin are available.
- To support early-discharge decisions in low-risk patients within an emergency department chest-pain pathway.
- To structure the handover and documentation of the risk assessment.
When not to use it
- ST-elevation myocardial infarction or new ischaemic ECG changes that already mandate urgent reperfusion.
- Haemodynamic instability, arrhythmia, or an obvious non-cardiac cause needing its own pathway (e.g. aortic dissection, pulmonary embolism).
- As a replacement for serial high-sensitivity troponin algorithms (e.g. ESC 0/1 h) where these are the local standard.
How it is calculated
| Criterion | Points |
|---|---|
| History | |
| Slightly suspicious | 0 |
| Moderately suspicious | 1 |
| Highly suspicious | 2 |
| ECG | |
| Normal | 0 |
| Non-specific repolarisation disturbance | 1 |
| Significant ST deviation | 2 |
| Age | |
| < 45 | 0 |
| 45–64 | 1 |
| ≥ 65 | 2 |
| Risk factors | |
| None | 0 |
| 1–2 risk factors | 1 |
| ≥ 3 risk factors or known atherosclerotic disease | 2 |
| Troponin | |
| ≤ normal limit | 0 |
| 1–3× normal limit | 1 |
| > 3× normal limit | 2 |
Clinical pearls and limitations
- Not for patients with ST-elevation or haemodynamic instability. Band risks come from a cohort using conventional troponin; high-sensitivity troponin pathways use their own local thresholds.
- Risk factors: hypercholesterolaemia, hypertension, diabetes, current or recent smoking, positive family history, obesity. Known atherosclerotic disease (prior MI, revascularisation, stroke, PAD) scores 2 regardless of count.
- The 'History' element is subjective; agreement between clinicians is moderate, so document what made the history suspicious.
- Troponin is scored against the assay's upper reference limit (≤ 1×, 1–3×, > 3×).
- The original 2008 cohort (122 patients) reported endpoint rates of 2.5 %, 20.3 % and 72.7 %; the band percentages shown here come from the larger 2013 validation.
- A low score supports, but does not replace, clinical judgement and safety-netting at discharge.
Frequently asked questions
What HEART score is safe for discharge?
Scores 0–3 were associated with 1.7 % six-week MACE in the prospective validation, and the HEART authors regard early discharge with outpatient follow-up as reasonable for this group. Local pathways often combine a low HEART score with serial troponin testing.
HEART score vs TIMI and GRACE?
In the Backus 2013 validation the HEART score discriminated better (c-statistic 0.83) than TIMI (0.75) and GRACE (0.70) for six-week MACE in unselected emergency chest-pain patients. GRACE remains the reference for in-hospital and long-term prognosis once ACS is diagnosed.
Can I use high-sensitivity troponin in the HEART score?
Yes, scored against the assay's 99th-percentile upper reference limit, but the published risk percentages come from cohorts using conventional assays. Rule-out timing is defined by the local high-sensitivity troponin protocol.
Evidence and guidelines
- Primary source: Six AJ, Backus BE, Kelder JC. Chest pain in the emergency room: value of the HEART score. Neth Heart J 2008;16(6):191-196.
- Backus BE et al. A prospective validation of the HEART score for chest pain patients at the emergency department. Int J Cardiol 2013;168(3):2153-2158 (2,440 patients, 10 Dutch hospitals; source of the band percentages).
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