HEART Score for Chest Pain

Methodology

HEART score (Six 2008)

History + ECG + Age (<45: 0, 45–64: 1, ≥65: 2) + Risk factors + Troponin (≤ normal limit 0, 1–2× 1, > 2× 2; each item 0–2)

Troponin bands follow the 2008 paper (1–2× and more than 2× the normal limit). Risk percentages are from the 2013 prospective validation in 2,440 patients (Backus); the 2008 paper reported 2.5%, 20.3% and 72.7%. Local high-sensitivity troponin pathways may differ.

Who it is for

Adults with undifferentiated chest pain in the emergency department; not for STEMI.

Version

1.1.0

How this calculator works

Where the formula comes from

• Six, Backus and Kelder introduced the HEART score in 2008 in the Netherlands from History, ECG, Age, Risk factors and Troponin, each scored 0–2; in 120 patients the endpoint rates were 2.5% (score 0–3), 20.3% (4–6) and 72.7% (7–10).^[1]
• A 2013 prospective validation in 2,440 patients at 10 Dutch hospitals found 6-week major adverse cardiac events in 1.7% (0–3), 16.6% (4–6) and 50.1% (7–10); its C-statistic (0.83) was higher than TIMI and GRACE.^[2]

The inputs

• In the 2008 paper, age under 45 scored 0, 45–65 scored 1 and 65 or over scored 2; risk factors were counted from hypertension, hypercholesterolaemia, diabetes, obesity, smoking and family history.^[1]
• In the 2008 paper, troponin scored 0 at or below the normal limit, 1 at 1–2 times and 2 at more than twice the normal limit.^[1]

Versions and alternatives

• The HEART Pathway combines the score with serial troponin testing and was evaluated in a 2015 randomised trial.^[3]

Where accuracy falls (published evidence)

• A 2021 methodological appraisal raised concerns about the score's derivation, interobserver reproducibility and omission of potentially relevant predictors, including sex.^[4]

What guidelines say

• The 2021 AHA/ACC chest pain guideline includes HEART-based pathways among the structured risk assessment tools used with troponin testing.^[5]

Sources

1. 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. doi:10.1007/BF03086144
2. Backus BE, Six AJ, Kelder JC, 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. doi:10.1016/j.ijcard.2013.01.255
3. Mahler SA, Riley RF, Hiestand BC, et al. The HEART Pathway randomized trial: identifying emergency department patients with acute chest pain for early discharge. Circ Cardiovasc Qual Outcomes. 2015;8(2):195–203. doi:10.1161/CIRCOUTCOMES.114.001384
4. Green SM, Schriger DL. A methodological appraisal of the HEART score and its variants. Ann Emerg Med. 2021;78(2):253–266. doi:10.1016/j.annemergmed.2021.02.007
5. Gulati M, Levy PD, Mukherjee D, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain. Circulation. 2021;144(22):e368–e454. doi:10.1161/CIR.0000000000001029

Compiled from the published sources above. Every statement was agreed independently by three AI research tools (Claude, ChatGPT, DeepSeek) and its source verified in PubMed or Crossref by the Hakeemly editorial team. Not reviewed by a doctor unless stated. Agreed on 2026-10-11

Worked example: how to calculate HEART score

An illustration with sample values, worked out with the same method the tool above uses.

Limitations

• Uses clinical judgement for the history component.

References

1. 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. doi:10.1007/BF03086144
2. Backus BE, Six AJ, Kelder JC, 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. doi:10.1016/j.ijcard.2013.01.255