The HEART score is the most widely used tool for stratifying undifferentiated chest pain in the emergency department. It identifies patients at low enough risk of a major adverse cardiac event (MACE) to discharge safely, while flagging those who need admission and an early invasive strategy.
How it works
Five components are each scored 0, 1, or 2, and the values are summed for a total from 0 to 10:
- History — clinical suspicion: 0 = slightly suspicious, 1 = moderately suspicious, 2 = highly suspicious.
- ECG — 0 = normal, 1 = non-specific repolarisation changes, 2 = significant ST deviation.
- Age — 0 = under 45, 1 = 45–64, 2 = 65 or over.
- Risk factors — 0 = none, 1 = one or two, 2 = three or more or known atherosclerotic disease.
- Troponin — 0 = at or below normal, 1 = one to three times normal, 2 = more than three times normal.
The total maps to a 6-week MACE risk band:
- 0–3 — low risk (~1.7%): consider discharge.
- 4–6 — moderate risk (~16.6%): admit for observation and serial troponin.
- 7–10 — high risk (~50.1%): early invasive management.
Scoring each component in practice
History (H) — the most subjective element
The History component captures the clinician’s gestalt. Highly suspicious history (score 2) means typical features: central, pressure-like chest pain, radiation to the left arm or jaw, onset with exertion, diaphoresis, and relief with nitrates. Slightly suspicious (score 0) means atypical features — sharp, positional, pleuritic, or reproduced by palpation — that make a cardiac cause unlikely.
ECG (E) — reading the rhythm
Normal sinus rhythm with no repolarisation changes scores 0. Non-specific changes such as ST depression less than 1 mm, T-wave flattening, or left bundle branch block in a known pattern score 1. New ST elevation, new LBBB, or ST depression of 1 mm or more scores 2. Use the pre-presenting ECG for comparison when available.
Troponin (T) — use your local assay
Score troponin against your laboratory’s reference range, not a published number. With high-sensitivity troponin assays now widely used, the 1× and 3× cut-offs still apply but the absolute values differ substantially from older assays. One serial troponin 3 hours after the first is standard with high-sensitivity assays; the HEART score incorporates whatever troponin is available at the time of scoring.
Worked examples
Low-risk presentation (score 2): A 38-year-old with sharp left-sided chest pain reproduced by palpation, normal ECG, no risk factors, and normal troponin: History 0 + ECG 0 + Age 0 + Risk 0 + Troponin 0 = 2 (low risk, consider discharge with return precautions).
Moderate-risk presentation (score 4): A 60-year-old (age 1) with central pressure-like chest pain rated moderately suspicious (History 1), non-specific T-wave changes (ECG 1), hypertension and diabetes as risk factors (Risk 1), and a normal troponin (Troponin 0) = 4 (moderate, admit for observation and serial troponin).
High-risk presentation (score 8): A 70-year-old with previous coronary stenting (age 2, risk 2), highly suspicious history (2), ST depression on ECG (2), and a troponin twice the upper limit (1) = 9 (high risk, early invasive management).
Limitations to keep in mind
The History component is the most subjective and the most influential; two clinicians assessing the same patient may score it differently. The HEART score validates best for the initial assessment in the emergency department — it was not designed for patients already known to have an ACS, for post-cardiac-arrest presentations, or for cases where the primary diagnosis is clearly non-cardiac. Always treat ongoing ischaemic pain on its own merits regardless of the total score, and integrate the HEART score with your institutional chest pain pathway rather than using it in isolation.