Scores the 6-week risk of a major cardiac event in a patient with chest pain in the emergency department.
Result
Answer the five items to see the score.
Sources
3 studies
3
studies
603
citations
730
PubMed papers
Evidence
Known limitations
In a retrospective multicenter analysis of 880 patients with chest pain at the cardiac emergency department, 0.99% of patients scoring 0 to 3 had a major adverse cardiac event within 6 weeks, 11.6% scoring 4 to 6 and 65.2% scoring 7 to 10.
In a randomized trial of 282 emergency patients, the HEART Pathway (score 0 to 3 with troponin normal at 0 and 3 hours) cut objective cardiac testing at 30 days by 12.1 percentage points (68.8% to 56.7%) and increased early discharge by 21.3 percentage points (18.4% to 39.7%). No patient identified for early discharge had a major adverse cardiac event at 30 days.
Circ Cardiovasc Qual Outcomes: Journal Metrics Score 5.6, Q1 · cited 425 times
PubMed · Free full text · DOI
In a stepped-wedge cluster randomized trial of 3,648 patients at nine Dutch hospitals, using the score was safe (6-week major adverse cardiac events were 1.3% lower than with usual care, within the non-inferiority margin; the rate in low-risk patients was 2.0%), but early discharge, readmissions and other health care use did not change significantly. Physicians were reluctant to forgo admission and tests in low-risk patients.
Ann Intern Med: Journal Metrics Score 4.6, Q1 · cited 215 times
The validation study has been cited 603 times, and 730 PubMed articles mention the HEART score in their title or abstract. Citation counts from OpenAlex and article counts from PubMed, retrieved November 15, 2026. Journal Metrics Scores and quartiles are from this site’s current release; follow the journal name for details.
After the result
Score 7 to 10 · Score 4 to 6 · Score 0 to 3
Manage as likely acute coronary syndrome. Observe and test further. Consider early discharge with a normal repeat troponin.
Next steps
Avoid common errors
5 common errors to avoid
and 3 more
When the score misleads
1Not for ST elevation
ST elevation, or a STEMI equivalent such as posterior infarction, needs the STEMI pathway, not a score.
2One troponin is not enough
The score was validated with the first troponin. Early discharge needs a repeat troponin, unless your high-sensitivity protocol allows single-sample rule-out. A score of 0 to 3 with a rising troponin is not low risk.
3History is subjective
How suspicious the history is depends on who takes it. Score it before seeing the troponin, and write down why.
4Raised troponin is not always coronary
Myocarditis, pulmonary embolism, takotsubo syndrome, sepsis and kidney disease raise troponin; the score treats them all the same.
5Age drives the score
A patient aged 65 or older with three or more risk factors, or known atherosclerotic disease, scores 4 before history, ECG or troponin are counted.
Formula
History, ECG, Age, Risk factors and Troponin, each 0 to 2; 0 to 3 low, 4 to 6 moderate, 7 to 10 high.
History, ECG, Age, Risk factors and Troponin, each 0 to 2; 0 to 3 low, 4 to 6 moderate, 7 to 10 high.
Items and score ranges
| Item | Finding | Points |
|---|---|---|
| H: History | Highly suspiciousModerately suspiciousSlightly suspicious | 210 |
| E: ECG | Significant ST depressionNonspecific repolarization disturbanceNormal | 210 |
| A: Age | 65 or older45 to 64Under 45 | 210 |
| R: Risk factors | 3 or more risk factors, or known atherosclerotic disease1 or 2 risk factorsNo known risk factors | 210 |
| T: Troponin | More than 3 times the normal limit1 to 3 times the normal limitAt or below the normal limit | 210 |
| Risk | Score | Major cardiac event in 6 weeks |
|---|---|---|
| Low risk | 0 to 3 | 1.7% |
| Moderate risk | 4 to 6 | 16.6% |
| High risk | 7 to 10 | 50.1% |
Risk factors
ECG
Major adverse cardiac events
Test cases
3 published cases, each also a test case
3 published cases; the calculator reproduces every score.
Worked examples
A 62-year-old man with hypertension came to the emergency department with a two-year history of intermittent retrosternal pressure, now coming on with activity. The ECG showed sinus rhythm with sinus arrhythmia and troponin was normal. The authors gave a HEART score of 2 for his age and hypertension. CT coronary angiography found an anomalous right coronary artery arising from the left side of the aorta, with high-risk features, and no inducible ischemia on stress testing.
“Hypertension and age accounted for his HEART score of 2.”
Age 45 to 64 and one risk factor (hypertension) score 1 each; the authors gave no points for the history, ECG or troponin. A low score did not rule out a structural coronary problem; he was managed with a beta-blocker. Many clinicians would give at least 1 point for an accelerating, exertional history.
Entered as: History: Slightly suspicious (0); ECG: Normal (0); Age: 45 to 64 (1); Risk factors: 1 or 2 risk factors (1); Troponin: At or below the normal limit (0).
Source: Sharma R et al., Cureus 2024 (PubMed · Free full text · DOI)
A 58-year-old man with hypertension and high cholesterol, treated with a calcium channel blocker and a statin, came to the emergency department with acute chest pain. His ECG showed changes without definite ischemia, and high-sensitivity troponin I was 11 and then 6 pg/mL, below the 20 pg/mL cut-off. His HEART score was 4. A stress echocardiogram showed anterior wall motion abnormalities, and catheterization found a 99% stenosis of the left main and left anterior descending arteries; he had coronary artery bypass grafting. A blinded research magnetocardiogram had also suggested ischemia.
“he had a HEART score of 4, with 1 point attributed to History, 1 point for ECG changes, 1 point attributed to age, and 1 point attributed to risk factors”
History 1, ECG 1, age 1 and risk factors 1 (two risk factors), troponin 0, as the authors scored it. A moderate score with normal troponin still needed further testing, which found severe disease.
Entered as: History: Moderately suspicious (1); ECG: Nonspecific repolarization disturbance (1); Age: 45 to 64 (1); Risk factors: 1 or 2 risk factors (1); Troponin: At or below the normal limit (0).
Source: Mace SE et al., Am Heart J Plus 2024 (PubMed · Free full text · DOI)
An 85-year-old woman with hypertension and chronic kidney disease came in after a fall, with a month of fatigue, exertional breathlessness and chest pressure. High-sensitivity troponin I was 8.840 ng/mL (normal below 0.045), and the ECG showed new T-wave inversions in the anterolateral leads with a QTc of 538 ms. Her HEART score was 8 and she was treated for a suspected NSTEMI. Coronary angiography showed only mild non-obstructive disease, and with apical hypokinesis on echocardiography the authors diagnosed stress-induced (takotsubo) cardiomyopathy.
“Her HEART score was 8.”
The authors gave only the total. Age 65 or older 2, troponin more than 3 times the limit 2 and one risk factor (hypertension) 1 are clear from the report; so this breakdown is our reconstruction: with new T-wave inversion scored 1 (nonspecific repolarization), the history would have been 2; scoring the T waves as ischemic (2) with a history of 1 also gives 8. A high score did not mean coronary occlusion; takotsubo syndrome scores like an acute coronary syndrome.
Entered as: History: Highly suspicious (2); ECG: Nonspecific repolarization disturbance (1); Age: 65 or older (2); Risk factors: 1 or 2 risk factors (1); Troponin: More than 3 times the normal limit (2).
Source: Singh A et al., Cureus 2022 (PubMed · Free full text · DOI)
FAQ
6 questions and answers
and 4 more answers
Questions
History, ECG, Age, Risk factors and Troponin. Each is scored 0, 1 or 2, so the total runs from 0 to 10. It was built in the Netherlands for patients with chest pain in the emergency department.
A score of 0 to 3. In the prospective validation of 2,440 patients, 1.7% of patients in this range had a major adverse cardiac event (death, myocardial infarction or coronary revascularization) within 6 weeks. Scores of 4 to 6 carried 16.6% and 7 to 10 carried 50.1%.
Often, but not on the score alone. The HEART Pathway trial combined a score of 0 to 3 with troponin that stayed normal at 0 and 3 hours, and found more early discharges and less testing with no adverse cardiac events at 30 days among those discharged early. The 2021 American chest pain guideline recommends structured clinical decision pathways of this kind for patients with suspected acute coronary syndrome.
It is the clinician’s judgement of how typical the story is of acute coronary syndrome: highly suspicious 2, moderately suspicious 1, slightly suspicious 0. Typical features include pressure-like pain, radiation to the arm, jaw or neck, onset on exertion and sweating. Relief with nitrates should not be taken as proof of a cardiac cause. It is the least reproducible item.
Your laboratory’s normal limit (the 99th percentile for high-sensitivity assays). The first troponin at or below that limit scores 0, 1 to 3 times the limit scores 1, and more than 3 times scores 2. Early discharge needs a repeat troponin, unless your high-sensitivity protocol allows single-sample rule-out (a very low level more than 3 hours after symptom onset).
No. ST elevation myocardial infarction needs immediate reperfusion. The score is for suspected acute coronary syndrome without ST elevation, and ST depression is what scores 2 on the ECG item.
Further reading
9 references with PubMed and DOI links
9
references
5
free full text
From Backus BE et al., Int J Cardiol 2013 to the newest case reports.
References
clinical grade of aneurysmal subarachnoid hemorrhage, I to V.
total calcium adjusted for albumin, in mg/dL or mmol/L.
stroke severity from 15 bedside items, 0 to 42.
MAP from systolic and diastolic pressure, against the 65 mm Hg target.
eye, verbal and motor scores for preverbal children, 3 to 15.
oxygenation ratio with the Berlin ARDS severity ranges.
serum sodium corrected for high glucose, Katz or Hillier factor.
sodium − (chloride + bicarbonate), with the albumin-corrected gap.
urea nitrogen to creatinine ratio, in US or SI units.
estimated creatinine clearance with actual, ideal or adjusted weight.
cardiac output and index from oxygen consumption and saturations.
ANC from the white cell count, neutrophils and bands.
insulin resistance from fasting glucose and insulin, in US or SI units.
FENa from plasma and urine sodium and creatinine: prerenal, indeterminate or tubular pattern.
three-item stroke severity screen for large vessel occlusion, 0 to 4.
water deficit in hypernatremia from sodium, weight and body water.
expected PaCO2 in metabolic acidosis, 1.5 × HCO3 + 8 ± 2.
corrected QT interval by Bazett, Fridericia, Framingham or Hodges.
head CT decision rule for children with minor head trauma.
blood loss before hemoglobin or hematocrit reaches a chosen lowest value.
eye, verbal and motor response, 3 to 15, with GCS-Pupils.
Devine ideal body weight and adjusted weight from height and sex.
cuffed and uncuffed tube size and oral depth by age.
calculated osmolality, osmolal gap and ethanol correction.
severity of alcohol-associated hepatitis from prothrombin time and bilirubin.
MELD, MELD-Na and MELD 3.0 for chronic liver disease.
early stroke risk after a transient ischemic attack.
whether a patient with blunt trauma needs cervical spine imaging.
prognosis from a Bruce protocol exercise test.
alveolar–arterial oxygen gradient from a blood gas.
whether an adult with minor head injury needs CT.
risk of advanced liver fibrosis from age, AST, ALT and platelets.
whether a pleural effusion is an exudate or a transudate.
cardiac risk before major noncardiac surgery, from six factors.
pre-test probability of pulmonary embolism, with the D-dimer step.
urine output by weight, KDIGO oliguria stage and fluid balance.
Contributed by Dr. Meng Zhao (MD · Former Neurosurgeon · Medical AI Researcher), from the original publications listed here. Last updated November 15, 2026. LinkedIn
The calculator code is tested against every worked example on this page before each release.
This calculator supports, and does not replace, clinical judgment. It is meant for healthcare professionals and is not medical advice for patients. Report an error through the contact page.