Printed on 3/17/2026
For informational purposes only. This is not medical advice.
The HEART Score is a clinical decision tool used in emergency departments to rapidly risk-stratify patients presenting with chest pain. It evaluates five components — History, ECG, Age, Risk factors, and Troponin — each scored 0–2 points. It helps clinicians identify low-risk patients who may be safely discharged versus those requiring further workup.
Formula: HEART = History(0–2) + ECG(0–2) + Age(0–2) + Risk Factors(0–2) + Troponin(0–2)
Obtain history of chest pain, review ECG, note patient age, count cardiovascular risk factors, and check the initial troponin result.
Rate each of the five HEART elements. History requires clinical judgment about how suspicious the presentation is for ACS.
Add the five scores (0-10 total). Low risk (0-3) may allow discharge; moderate risk (4-6) needs observation; high risk (7-10) warrants invasive evaluation.
Emergency physicians, PAs, NPs
Rapidly stratify chest pain patients upon arrival. Low HEART scores can be discharged after negative serial troponins, reducing unnecessary admissions.
Hospitalists, ED observation teams
Determine which patients need 23-hour observation vs. immediate discharge vs. inpatient admission based on risk stratification.
Hospital quality teams
Incorporate HEART into institutional chest pain protocols. Many hospitals now mandate HEART scoring for all undifferentiated chest pain presentations.
Clinicians and patients
Use the score to explain risk to patients. 'Your score is 2, meaning less than 2% chance of a heart event in 6 weeks' facilitates informed discharge decisions.
Medical students, residents
Learn structured approach to chest pain evaluation. HEART teaches systematic assessment of history, ECG, and risk factors.
Healthcare administrators
Reduce stress testing and admissions for low-risk chest pain. HEART pathways have been shown to safely decrease healthcare costs.
Score 0 for non-anginal pain (reproducible, positional, pleuritic). Score 1 for moderately suspicious (some typical features). Score 2 for classic angina (exertional substernal pressure radiating to arm/jaw, relieved by rest/nitrates).
If the ECG shows ST elevation, activate the cath lab immediately. HEART is for undifferentiated chest pain without obvious STEMI. Don't calculate HEART if you already have a STEMI.
With high-sensitivity troponin assays, very small elevations are common. Score troponin based on multiples of the upper limit of normal for YOUR assay, not absolute values.
Risk factors: hypertension, hyperlipidemia, diabetes, obesity (BMI >30 - assess with [BMI Calculator](/tools/bmi-calculator)), current/recent smoker, family history of premature CAD (assess with [ASCVD Risk Calculator](/tools/ascvd-risk) or [Framingham Risk Score](/tools/framingham-risk)). Known atherosclerosis (prior MI, PCI, CABG, PAD, stroke) automatically scores 2.
Even with HEART 0-3, most protocols require two troponins 3-6 hours apart before discharge. A single negative troponin doesn't rule out evolving MI, especially early in the presentation.
The HEART-Pathway is HEART score 0-3 PLUS two negative troponins 3 hours apart. This protocol has been validated for safe discharge without stress testing in multiple studies.
Age <45 = 0 points. Age 45-64 = 1 point. Age ≥65 = 2 points. There's no adjustment for 'young for their risk factors.' A 44-year-old diabetic smoker still gets 0 for age.
Score ECG as 1 for non-specific ST changes, T wave flattening/inversion not known to be old, left bundle branch block, LVH with repolarization changes, or digoxin effect.
A low HEART score doesn't mean the patient is well — it means ACS is unlikely. Still consider PE (assess with [Wells PE Score](/tools/wells-pe-score)), aortic dissection, pericarditis, esophageal rupture, and other serious causes. For pneumonia severity, use [CURB-65](/tools/curb-65).
Write 'HEART score 3 (H1, E0, A0, R1, T1) — low risk for MACE' in your note. This documents your structured approach and communicates clearly to consultants and follow-up providers.
HEART Score was developed by Six et al. (Netherlands Heart J 2008) and validated in multiple studies. The HEART-Pathway (Mahler et al., JAMA Intern Med 2015) demonstrated safe discharge without stress testing for HEART 0-3 with negative serial troponins. MACE rates by score category are from the original validation and subsequent meta-analyses.
Your HEART score ranges from 0 to 10 and stratifies your risk of a major adverse cardiac event (MACE) — including myocardial infarction, need for revascularization, or death — within 6 weeks of presentation. A score of 0–3 is low risk, with a MACE rate of approximately 0.9–1.7%. A score of 4–6 is moderate risk, with a MACE rate of 12–16.6%. A score of 7–10 is high risk, with a MACE rate of 50–65%.
Low-risk patients (0–3) may be candidates for early discharge from the emergency department after appropriate evaluation, potentially avoiding unnecessary hospital admissions and invasive testing. Moderate-risk patients typically require observation, serial troponins, and further cardiac workup. High-risk patients should be considered for early invasive strategies such as cardiac catheterization.
Use this calculator in the emergency department when evaluating adult patients presenting with chest pain or symptoms suspicious for acute coronary syndrome (ACS). It is designed to be applied early in the evaluation — after the initial history, ECG, and first troponin result are available — to guide disposition decisions.
The HEART score is particularly valuable for identifying the large proportion of chest pain patients who are at low risk and may be safely discharged, reducing unnecessary admissions, stress testing, and healthcare costs. It is now incorporated into clinical pathways at many hospitals as part of standardized chest pain evaluation protocols.
The HEART score includes a subjective component — the History element requires clinical judgment to classify the presentation as slightly, moderately, or highly suspicious for ACS. This introduces inter-rater variability, and less experienced clinicians may score this component differently than cardiologists or experienced emergency physicians.
The score was developed and primarily validated in emergency department populations and should not be applied to patients with clear STEMI (ST-elevation myocardial infarction), who require immediate intervention regardless of score. It also does not account for certain high-risk features such as hemodynamic instability, new heart failure, or sustained ventricular arrhythmias, which may warrant aggressive management even with a lower HEART score. Finally, while a score of 0–3 carries a low MACE rate, it is not zero — clinical judgment and patient-specific factors should always supplement the score.
For related assessments, see Framingham Risk, CHA₂DS₂-VASc Score and TIMI NSTEMI.
Disclaimer: This tool is for educational and informational purposes only. It is not a substitute for professional medical advice, diagnosis, or treatment. Always consult a qualified healthcare provider with questions about your health.
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