Origin of the HEART Score

Origin of the HEART Score

Rob Orman MD and Barbra Backus MD

Take Home Points

• The HEART score has a high diagnostic accuracy of predicting major adverse cardiac events in patients with chest pain.
• The HEART score should not supplant clinical judgment.
• Data on the ability of the HEART score to decrease resource utilization has been mixed.

• Backus, BE et al. 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.PMID: 23465250
• The HEART score has 5 components; history, EKG, age, risk factors and troponin level.

Backus found that the HEART score has a high diagnostic accuracy of predicting major adverse cardiac events in patients with chest pain. After the first validation study, they performed a retrospective multicenter validation study followed by a prospective validation study. The results of these studies were the same as the pilot study.Modified from: Backus et al.

• The HEART score is capable of identifying patients at both ends of the spectrum of risk. This is different than other scoring systems such as TIMI and GRACE score. These were better at identifying patients with acute coronary syndrome or NSTEMI but not excluding patients from acute coronary syndrome.
• A patient can have an elevated troponin greater than 2 times the upper limit of normal or significant ST depressions and still have a low risk score. Backus feels it is important to remember that the HEART score is not supposed to replace our clinical thinking and reasoning. It was meant as guidance to give the provider direction in a broad selection of chest pain patients. In over 10,000 patients in validation, they never had a heart score of 2 based solely on elevation of troponin. When the patient has EKG findings such as ST depression, the treating physician should look carefully at these patients and overrule the HEART score if necessary.
• Mahler, SA et al. The HEART Pathway randomized trial: identifying emergency department patients with acute chest pain for early discharge. Circ Cardiovasc Qual Outcomes. 2015 Mar;8(2):195-203.PMID: 25737484
• A criticism of the HEART pathway is the inclusion of cardiac risk factors in the score.
  • The presence of several cardiac risk factors carries as much weight as elevated biomarkers or EKG changes. Per Backus, the HEART score was based on clinical experience and expert opinion. When evaluating a patient with chest pain, every physician also considers the history of the patient, EKG and troponin levels but also the age and cardiovascular risk profile. The risk factors have the same weight as the other elements.
  • During the validation process, they performed linear regression and found that age and cardiac risk factors are the weaker elements of the heart score. The group considered giving different weights to different risk factors. However, this did not affect the ability to risk stratify and made the tool more complicated.
  • Patients with multiple risk factors are more prone to developing coronary artery disease and acute coronary syndrome.
• Patients evaluated with a single high sensitivity troponin will usually still occupy a room in the emergency department for 2.5 hours. Although the HEART score was sensitive with single troponin, treating physicians often elect for two troponins spaced by an interval of time.
• If the troponin is slightly elevated, Backus repeats after 2 or 3 hours and makes a decision afterwards.
• Poldervaart, JM et al. Effect of using the HEART score in patients with chest pain in the emergency department: a stepped-wedge, cluster randomized trial. Ann Inter Med. 2017 May 16;166(10):689-697.PMID: 28437795
  • 3666 patients were included in the study. Half received usual care defined as the daily practice of an attending physician to evaluate chest pain without using the HEART score. The other half had care determined by formal calculation of the HEART score.
  • Unfortunately, they were unable to show a major difference between the HEART score and usual care in terms of resource utilization. There was a small decrease in exercise EKG testing but they did not show a decrease in admission rates or health care costs. There was non-adherence to the protocol. Physicians were hesitant to discharge low risk patients from the emergency department without further testing.
  • The study was performed between 2013-2014, when there was less data available on outcomes after using the HEART score. If the study was performed now, providers may be more comfortable discharging low risk patients.
• The Mahler study found that implementing the HEART score significantly reduced the length of stay, cost of evaluation and admission rate. They had perfect adherence to the protocol. This was a single center study.