HEART Score Calculator (chest pain)

Understanding the HEART score — concept and principle

The HEART score estimates the short-term risk of a major adverse cardiac event (MACE), such as heart attack, the need for coronary revascularisation or death, in patients who come to the emergency department with chest pain. It is used to identify people who can safely go home early and those who need further testing or admission.

How it is calculated

Five elements are each scored 0, 1 or 2:

• History: slightly, moderately or highly suspicious for acute coronary syndrome.
• ECG: normal; non-specific repolarisation changes; significant ST deviation.
• Age: below 45; 45–64; 65 or over.
• Risk factors: none; one or two; three or more, or known atherosclerotic disease. Typical risk factors are high cholesterol, hypertension, diabetes, smoking, family history and obesity.
• Troponin: at or below the normal limit; 1–3 times the limit; more than 3 times.

The total is 0 to 10. Risk groups: 0–3 low (MACE about 1–2% at six weeks), 4–6 moderate (about 12–17%), 7–10 high (about 50–65%).

The principle

Chest pain has many causes, and most are not cardiac. Six, Backus and Kelder (2008) combined the elements clinicians already weigh, namely the story, the ECG, age, risk factors and a blood marker of heart muscle injury, into one simple score with equal weights. Low-risk patients have so few events that the risks of further testing, such as false positives and invasive procedures, can outweigh the benefit. High scores identify patients who usually need early invasive management.

Worked example

1. Defaults: slightly suspicious history (0), normal ECG (0), age 45–64 (1), one or two risk factors (1), troponin at or below the limit (0).
2. HEART score = 0 + 0 + 1 + 1 + 0 = 2.
3. 2 is 3 or less, so the risk group is low (MACE ~1–2%).

How to read the result

With a low score, many pathways support early discharge with outpatient follow-up, usually once serial troponin testing is also negative. A moderate score usually means observation, repeat troponin and further testing. A high score points to early cardiology involvement and possible invasive treatment. The percentages are averages from validation studies and vary with the population and troponin assay.

Common mistakes

• Calculating the score with a single early troponin when the pathway requires a repeat test.
• Scoring the history as low out of habit; it is the most subjective element.
• Using it for patients with obvious ST-elevation myocardial infarction, who need immediate treatment instead.

Frequently asked questions

What does MACE include?

In HEART studies, major adverse cardiac events usually include acute myocardial infarction, coronary revascularisation and death within about six weeks.

Does a score of 0 mean no heart problem?

No. It means a very low short-term risk of major events, not proof that the heart is healthy.

Sources: Six A. J., Backus B. E., Kelder J. C., Netherlands Heart Journal, 2008 · Backus B. E. et al., International Journal of Cardiology, 2013 (prospective validation)