HEART Score for Major Cardiac Events

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.

*History

Chest Pain Features

*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.

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