The HEART Score's Blind Spots

The HEART score has been widely adopted by emergency physicians since its publication in 2008. EPs seem to like it and use it appropriately. Some ED staffing companies even recommend or require its use. Even some of my hospitalists know it, but, unfortunately, they seem to use it primarily to block admissions by giving patients a lower score than I do or to deny the possibility of unstable angina. The HEART score doesn't have the best interrater reliability. This is typically based on the interpretation of the history or the ECG. This scoring difference obviously becomes important when one physician gives a 3 and the other a 4, leading to disagreement on risk for 30-day major adverse cardiac events (MACE) and final disposition.

HEART Pathway for Early Discharge in Acute Chest Pain

Identifies emergency department patients with acute chest pain for early discharge.

EDACS (Emergency Department Assessment of Chest Pain Score}

Identifies chest pain patients with low risk of major adverse cardiac event. This score only applies to patients: (1) ≥18 years old with normal vital signs; (2) Chest pain consistent with ACS; (3) No ongoing chest pain or crescendo angina.

HEART Score for Major Cardiac Events

Predicts 6-week risk of major adverse cardiac event. Use in patients ≥21 years old presenting with symptoms suggestive of ACS. Do not use if new ST-segment elevation ≥1 mm or other new EKG changes, hypotension, life expectancy less than 1 year, or noncardiac medical/surgical/psychiatric illness determined by the provider to require admission.

TIMI Risk Score for STEMI

Estimates mortality in patients with STEMI.

TIMI Risk Score for UA/NSTEMI

Estimates mortality for patients with unstable angina and non-ST elevation MI.

A modified HEART risk score in chest pain patients with suspected non-ST-segment elevation acute coronary syndrome

In conclusion, the modified HEART risk score was validated in chest pain patients with suspected NSTE-ACS and may complement MACE risk assessment and patients triage in the ED. A prospective study of the score is warranted.

Chest pain in the emergency room: value of the HEART score

The HEART score is an easy, quick and reliable predictor of outcome in chest pain patients and can therefore be used for triage.

Emergency Department Assessment of Chest Pain Score (EDACS)

The goal of these rules is to identify a low-risk population of patients who need less testing than other, higher-risk patients. As a rule-out calculator, the EDACS is good at identifying who is relatively safe to go home (highly sensitive), but not good at identifying who does have the disease (not terribly specific).

New tool helps emergency medicine physicians provide more personalized care to patients with chest pain

The study found that both the RISTRA-ACS and the HEART pathway risk scores accurately identified very low-risk patients. However, the RISTRA-ACS risk score was found to be better than the HEART score, troponin tests alone, and physician judgement in distinguishing which patients would experience a major heart problem within 60 days. In addition, the RISTRA-ACS tool accurately risk stratified more than 50% of the patients with only a single troponin measurement, whereas the EDACS-ADP and HEART pathway require multiple troponin tests.

The HEART Score

The HEART score has been validated in several studies and has proven to be a powerful, easy, and above all practical instrument to separate patients into a low, medium and high risk groups. Patients scoring 0-3 have a 1.6% chance of experiencing a cardiac event, those with a score 4-6 have a 13% chance, and those scoring 7 or higher have a 50% chance of developing a myocardial infarction, PTCA, CABG or death within 6 weeks following presentation.

The Real-World Calculation of the HEART Score

ED clinicians had only moderate agreement with research HEART scores. Combined with uncertainties regarding accuracy in predicting major adverse cardiac events, we urge caution in the widespread use of the HEART score as the sole determinant of ED disposition.

TIMI Risk Score for UA/NSTEMI

The TIMI Risk Score for UA/NSTEMI can be used to help risk stratify patients with presumed ischemic chest pain. However, it was originally derived in patients with confirmed unstable angina or non-ST elevation myocardial infarction.

Vancouver Chest Pain Rule

e. The Vancouver Chest Pain Rule identifies low-risk chest pain patients who can be safely discharged from the ED after the standard initial evaluation of history and physical examination, ECG, and 1 cardiac biomarker (usual-sensitivity troponin).