There are approximately 8 million ED visits annually in the United States for chest pain. 10%-20% go on to receive an acute coronary syndrome diagnosis. The goal of the ED physician is to differentiate between ischemic chest pain and other, more benign causes of chest pain. Historical features and laboratory values are helpful, but 2%-5% of patients with true ACS will go on to be inappropriately discharged.

The HEART score was developed to assist clinicians in stratifying ED patients with chest pain. Its derivation was based on expert opinion and the existing literature. The 5 predictors in the tool are history (H), EKG (E), age (A), risk factors (R), and troponin (T).

A heart score of 0-3 suggests a low risk of major adverse cardiac event (MACE) and discharge should be considered. A score of 4-6 is intermediate and 7-10 is high risk. The risk score’s usefulness has been independently validated in numerous studies conducted worldwide. Undeterred, Fernando and colleagues at the University of Ottawa recently published a systematic review and meta-analysis on all of the existing studies in order to evaluate the prognostic accuracy of the HEART score for prediction of MI and mortality.

In their analysis of 30 studies (n=44,202), a HEART score above the low risk threshold (> or = 4) had a sensitivity of 95% and specificity of 45% for MACE. A high-risk HEART score had a specificity of 95%. Their results provided further support for the excellent performance of the HEART score for the prediction of MACE. The HEART score should be the primary clinical decision instrument for ED physicians evaluating the all too familiar patient with chest pain.