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HEART Score for Major Cardiac Events

Predicts 6-week risk of major adverse cardiac events.

CréateurDr. Barbra Backus, MD, PhD
Essayer
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Instructions

 Indications

  • Presents with symptoms suggestive of acute coronary syndrome (ACS)

  • ≥ 21 years old

 

Contraindications

  • New ST-segment elevation ≥ 1 mm or other new EKG changes requiring immediate intervention

  • Hypotension or clinically unstable patients

  • Patients already diagnosed with ACS

  • Life expectancy < 1 year

  • Noncardiac medical/surgical/psychiatric illness requiring admission

Chest Pain Features

 

High Risk FeaturesLow Risk Features
  • Retrosternal pain, pressure
  • Radiation to jaw/left shoulder/arms
  • Duration 5-15 min
  • Initiated by exercise, cold, emotion
  • Perspiration
  • Nausea/vomiting
  • Reaction on nitrates within minutes
  • Well-localized
  • Sharp
  • Non-exertional
  • No diaphoresis
  • No nausea or vomiting
  • Reproducible with palpation

 

 

Introduction

The HEART Score identifies patients with higher risk of having a major adverse cardiac event or MACE (all-cause mortality, myocardial infarction or coronary revascularization) in the following 6 weeks. It is intended to assist emergency department providers risk-stratify undifferentiated chest pain patients into low, moderate and high-risk groups. The HEART Score can guide management and improve resource utilization by differentiating groups who can be managed outpatient verses inpatient monitoring with or without invasive interventions. HEART is an acronym for History, Age, Risk factors and Troponin. The provider will need to take a detailed chest pain history and have some skill in reading EKGs to adequately address two components of the score. Older ACS scores (TIMI Score for UA/NSTEMI or GRACE ACS Risk Score) measure risk of death for patients with diagnosed acute coronary syndrome (ACS). However, the HEART Score is not intended for those already diagnosed with ACS and outperforms the TIMI Score in safely identifying more low-risk patients. Do not use the HEART Score if the patient presents with new ST-segment elevation requiring immediate intervention or clinically unstable patients.

HEART is an acronym for History, Age, Risk factors and Troponin components of the Heart Score. Each component is scored with 0, 1 or 2.

 

0 Points

1 Point

2 Points

History*

Slightly suspicious

Moderately suspicious

Highly suspicious

EKG

Normal

Non-specific repolarization disturbance*

Significant ST deviation*

Age (years)

< 45

45-64

≥ 65

Risk Factors*

No known risk factors

1-2 risk factors

≥ 3 risk factors or history of atherosclerotic disease

Initial Troponin*

≤ normal limit

1-3x normal limit

> 3x normal limit

*History

Chest Pain Features

High Risk Features

Low Risk Features

  • Retrosternal pain, pressure

  • Radiation to jaw/left shoulder/arms

  • Duration 5-15 min

  • Initiated by exercise, cold, emotion

  • Perspiration

  • Nausea/vomiting

  • Reaction on nitrates within minutes

  • Well-localized

  • Sharp

  • Non-exertional

  • No diaphoresis

  • No nausea or vomiting

  • Reproducible with palpation

 

*Non-specific Repolarization Disturbance

  • No ST deviation

  • LBBB

  • Typical changes suggesting LVH, 

  • Repolarization disorders (i.e. digoxin)

  • Unchanged known repolarization disorders

 

*Significant ST Deviation

  • ST deviation not due to LBBB, LVH or digoxin

 

*Risk Factors

  • HTN

  • Hypercholesterolemia

  • DM

  • Obesity (BMI > 30 kg/m²)

  • Smoking (current or cessation ≤ 3 months)

  • Positive family history (parent or sibling with CVD before age 65)

  • Atherosclerotic disease

    • Prior MI

    • PCI/CABG

    • CVA/TIA

    • Peripheral arterial disease

 

*Initial Troponin

  • Use local, regular sensitivity troponin assays and corresponding cutoffs.

 

Management

Low Score (0-3 pts): MACE Risk 0.9 - 1.7%

  • In the HEART Score study, these patients were discharged (0.99% in the retrospective study, 1.7% in the prospective study).

  • If troponin is positive, many experts recommend further workup and admission even with a low HEART Score.

  • If EKG is highly suspicious, many experts recommend further workup and admission even with a low HEART Score.

Moderate Score (4-6 pts): MACE Risk 12 - 16.6%

  • In the HEART Score study, these patients were admitted to the hospital (11.6% in the retrospective study, 16.6% in the prospective study).

  • If troponin is positive, many experts recommend further workup and admission even with a low HEART Score.

  • If EKG is highly suspicious, many experts recommend further workup and admission even with a low HEART Score.

 

High Score (7-10 pts): MACE Risk 50 - 65%

  • In the HEART Score study, these patients were candidates for early invasive measures (65.2% in the retrospective study, 50.1% in the prospective study).

 A MACE (Major Adverse Cardiac Event) was defined as all-cause mortality, myocardial infarction, or coronary revascularization.

Toutes les questions et résultats possibles

GuidanceTitre non visible
History

Chest Pain Features

 

High Risk FeaturesLow Risk Features
  • Retrosternal pain, pressure
  • Radiation to jaw/left shoulder/arms
  • Duration 5-15 min
  • Initiated by exercise, cold, emotion
  • Perspiration
  • Nausea/vomiting
  • Reaction on nitrates within minutes
  • Well-localized
  • Sharp
  • Non-exertional
  • No diaphoresis
  • No nausea or vomiting
  • Reproducible with palpation

 

 

Select one option:

  • Slightly suspicious
  • Moderately suspicious
  • Highly suspicious
EKG

Non-specific repolarization disturbance

  • No ST deviation
  • LBBB
  • Typical changes suggesting LVH, 
  • Repolarization disorders (i.e. digoxin)
  • Unchanged known repolarization disorders

 

Significant ST deviation

  • ST deviation not due to LBBB, LVH or digoxin

 

Select one option:

  • Normal
  • Non-specific repolarization disturbance
  • Significant ST deviation
Age

Select one option:

  • < 45 years
  • 45 - 64 years
  • ≥ 65 years
Risk Factors

HTN

Hypercholesterolemia

DM

Obesity (BMI > 30 kg/m²)

Smoking (current or cessation ≤ 3 months)

Positive family history (parent or sibling with CVD before age 65)

Atherosclerotic disease

  • Prior MI
  • PCI/CABG
  • CVA/TIA
  • Peripheral arterial disease

 

Select one option:

  • No known risk factors
  • 1 - 2 risk factors
  • ≥ 3 risk factors or history of atherosclerotic disease
Initial Troponin

Use local, regular sensitivity troponin assays and corresponding cutoffs.

Select one option:

  • ≤ normal limit
  • 1 - 3x normal limit
  • > 3x normal limit
Résultats possibles
Moderate Score (4-6 pts): MACE Risk 12 - 16.6%

In the HEART Score study, these patients were admitted to the hospital (11.6% in the retrospective study, 16.6% in the prospective study).

 

A MACE (Major Adverse Cardiac Event) was defined as all-cause mortality, myocardial infarction, or coronary revascularization.

Moderate Score (4-6 pts): MACE Risk 12 - 16.6%*

In the HEART Score study, these patients were admitted to the hospital (11.6% in the retrospective study, 16.6% in the prospective study).

 

*If troponin is positive, many experts recommend further workup and admission even with a lower HEART Score.

 

A MACE (Major Adverse Cardiac Event) was defined as all-cause mortality, myocardial infarction, or coronary revascularization.

Low Score (0-3 pts): MACE Risk 0.9 - 1.7%

In the HEART Score study, these patients were discharged (0.99% in the retrospective study, 1.7% in the prospective study).

 

A MACE (Major Adverse Cardiac Event) was defined as all-cause mortality, myocardial infarction, or coronary revascularization.

Low Score (0-3 pts): MACE Risk 0.9 - 1.7%*^

In the HEART Score study, these patients were discharged (0.99% in the retrospective study, 1.7% in the prospective study).

 

*If troponin is positive, many experts recommend further workup and admission even with a low HEART Score.

 

^If EKG is highly suspicious, many experts recommend further workup and admission even with a low HEART Score.

 

A MACE (Major Adverse Cardiac Event) was defined as all-cause mortality, myocardial infarction, or coronary revascularization.

Moderate Score (4-6 pts): MACE Risk 12 - 16.6%^

In the HEART Score study, these patients were admitted to the hospital (11.6% in the retrospective study, 16.6% in the prospective study).

 

^If EKG is highly suspicious, many experts recommend further workup and admission even with a lower HEART Score.

 

A MACE (Major Adverse Cardiac Event) was defined as all-cause mortality, myocardial infarction, or coronary revascularization.

Low Score (0-3 pts): MACE Risk 0.9 - 1.7%^

In the HEART Score study, these patients were discharged (0.99% in the retrospective study, 1.7% in the prospective study).

 

^If EKG is highly suspicious, many experts recommend further workup and admission even with a low HEART Score.

 

A MACE (Major Adverse Cardiac Event) was defined as all-cause mortality, myocardial infarction, or coronary revascularization.

High Score (7-10 pts): MACE Risk 50 - 65%

In the HEART Score study, these patients were candidates for early invasive measures (65.2% in the retrospective study, 50.1% in the prospective study).

 

A MACE (Major Adverse Cardiac Event) was defined as all-cause mortality, myocardial infarction, or coronary revascularization.

Moderate Score (4-6 pts): MACE Risk 12 - 16.6%*^

In the HEART Score study, these patients were admitted to the hospital (11.6% in the retrospective study, 16.6% in the prospective study).

 

*If troponin is positive, many experts recommend further workup and admission even with a lower HEART Score.

 

^If EKG is highly suspicious, many experts recommend further workup and admission even with a low HEART Score.

 

A MACE (Major Adverse Cardiac Event) was defined as all-cause mortality, myocardial infarction, or coronary revascularization.

Low Score (0-3 pts): MACE Risk 0.9 - 1.7%*

In the HEART Score study, these patients were discharged (0.99% in the retrospective study, 1.7% in the prospective study).

 

*If troponin is positive, many experts recommend further workup and admission even with a low HEART Score.

 

A MACE (Major Adverse Cardiac Event) was defined as all-cause mortality, myocardial infarction, or coronary revascularization.

Citation

Six AJ, Backus BE, Kelder JC. Chest pain in the emergency room: value of the HEART score. Neth Heart J. 2008 Jun;16(6):191-6.

Bibliographie

  • Chest pain in the emergency room: value of the HEART score. Neth Heart J. 2008 Jun;16(6):191-6.

    Six AJ, Backus BE, Kelder JC.

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2442661/

  • Chest pain in the emergency room: a multicenter validation of the HEART Score. Crit Pathw Cardiol. 2010 Sep;9(3):164-9.

    Backus BE, Six AJ, Kelder JC, Mast TP, van den Akker F, Mast EG, Monnink SH, van Tooren RM, Doevendans PA.

    https://pubmed.ncbi.nlm.nih.gov/20802272/

  • A prospective validation of the HEART score for chest pain patients at the emergency department. Int J Cardiol. 2013 Oct 3;168(3):2153-8.

    Backus BE, Six AJ, Kelder JC, Bosschaert MA, Mast EG, Mosterd A, Veldkamp RF, Wardeh AJ, Tio R, Braam R, Monnink SH, van Tooren R, Mast TP, van den Akker F, Cramer MJ, Poldervaart JM, Hoes AW, Doevendans PA.

    https://pubmed.ncbi.nlm.nih.gov/23465250/

  • The HEART Pathway Randomized Controlled Trial One-year Outcomes. Acad Emerg Med. 2019 Jan;26(1):41-50.

    Stopyra JP, Riley RF, Hiestand BC, Russell GB, Hoekstra JW, Lefebvre CW, Nicks BA, Cline DM, Askew KL, Elliott SB, Herrington DM, Burke GL, Miller CD, Mahler SA.

    https://pubmed.ncbi.nlm.nih.gov/29920834/

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