Chest pain representing acute coronary syndrome (ACS) is the most common reason patients presenting to the emergency department (ED) are admitted to the hospital. The treatment for ACS is early targeted therapy and missed cases results in increased morbidity and mortality. As a result many clinicians choose to admit patients for further evaluation, resulting in further testing and higher medical costs. The HEART score was developed in order to risk stratify these patients. The score is an acronym for history, EKG, age, risk factors, and troponin. Unlike other clinical decision rules, the components are scored 0, 1, or 2, allowing for a middle ground, and this CDR was uniquely developed for use in the ED. This research group has previously performed prospective validation studies assessing the HEART score. In this paper, the group compared the HEART, TIMI, and GRACE clinical decision rules and their ability to risk stratify low risk chest pain patients.

Clinical Question

How does the HEART score compare to TIMI and GRACE scores in determining low risk chest pain patients?


All patients presenting to ten emergency departments in the Netherlands between October 2008 and November 2009 who complained of chest pain.


HEART score


TIMI and GRACE score


Primary: Major Adverse Cardiac Event (MACE): Acute myocardial injury, PCI, CABG, coronary angiography showing correctable disease that was managed conservatively, death due to any cause.
Secondary: 6 week occurrence of MI or death, diagnosis of ACS within 3 months of presentation, coronary angiography within 3 months of presentation


Prospective, observational study (history was taken prospectively, but EKGs read by cardiologist retrospectively)


Patients who complained of dyspnea and palpitations, Additionally, those patients with EKGs notable for STEMI prehospital (these patients were transported to specific hospitals)

Primary Results

  • 2440 patients included in enrollment
    • 52 patients had invalid data on admission or lost to follow up
    • 2388 followed for sufficient length to be included in study
  • 407 patients (17%) had a MACE in entire study group
    • 155 patients (6.4%) with AMI
    • 251 patients (10.5%) underwent PCI
    • 67 patients (2.8%) had a CABG
    • 44 patients (1.8%) had coronary angio with conservatively managed correctable stenosis

Critical Results

Clinical Decision Rule

Low risk score

MACE (%)




15 (1.7%)


TIMI Score


23 (2.8%)




10 (2.9%)



  • Study asked a simple, clinically relevant question with patient centered outcome
  • All data on HEART score is based on ED patients
  • Large, multicenter study
  • Excellent follow up (~98% of patients enrolled)


  • Variability in history taking and EKG interpretation could lead to significant variation in provider scoring
  • Primary endpoint (MACE) is a composite with individual pieces that are not equally patient relevant (i.e. death is not the same as AMI)
  • Although the study is designed to capture all patients who presented with chest pain, there is always potential for missed cases
  • Overall MACE rate (17%) higher than in other health care systems (i.e. US)
  • C-statistics (AUC) measure accuracy which gives equal weight to sensitivity and specificity. In the emergency department, we are more concerned about discharging false negatives than admitting false positives. In other words, sensitivity is much more important to our clinical decision making than specificity. Therefore, comparing the sensitivities of these tests is probably more applicable towards ED management than the C-statistic composite

Author's Conclusions

“The HEART score provides the clinician with a quick and reliable predictor of outcome, without computer-required calculating. Low HEART scores (0–3), exclude short-term MACE with >98% certainty. In these patients one might consider reserved policies. In patients with high HEART scores (7–10) the high risk of MACE may indicate more aggressive policies.”

Our Conclusions

In this observational cohort stufy, the HEART score more accurately identifies a low risk group of ED chest pain patients in comparison to either the TIMI or GRACE scores Further external validation studies examining the score in various populations would be beneficial

Potential Impact To Current Practice

Clinicians should consider adoption of the HEART score over TIMI or GRACE for chest pain risk stratification. Since this study, additional external validation studies have been performed (including the HEART pathway) demonstrating the utility of this tool.

Bottom Line

The HEART score appears to be a superior clinical decision tool for risk stratification of chest pain patients in the ED when compared to the TIMI and GRACE scores.

Read More

REBEL EM: The HEART Score: A New ED Chest Pain Risk Stratification Score

REBEL EM: Is It Time to Start Using the HEART Pathway in the Emergency Department