Validation of the HEART Score in Patients with Undifferentiated Chest Pain: A Prospective Cohort Study
DOI:
https://doi.org/10.48165/ajm.2026.9.01.8Keywords:
HEART score; chest pain; acute coronary syndrome; major adverse cardiac events; risk stratification; emergency department; validation studyAbstract
Background: Chest pain represents one of the most common and challenging presentations in emergency medicine, requiring rapid differentiation between life-threatening cardiac conditions and benign etiologies. The HEART score was developed to risk stratify patients with chest pain for major adverse cardiac events (MACE), yet validation across diverse populations and healthcare settings remains essential for confident clinical implementation. Methods: A prospective observational cohort study was conducted at our tertiary care hospital over 20 months, enrolling 892 adult patients presenting with chest pain suggestive of possible acute coronary syndrome. HEART scores were calculated at presentation, and patients were followed for 6 weeks. The primary outcome was occurrence of MACE, defined as acute myocardial infarction, percutaneous coronary intervention, coronary artery bypass grafting, or all-cause mortality. Results: The mean age was 54.8 ± 14.2 years, with 58.4% male patients. The mean HEART score was 4.2 ± 1.8. MACE occurred in 142 patients (15.9%). The area under the ROC curve for MACE prediction was 0.867 (95% CI: 0.838–0.896). Low-risk patients (HEART score 0-3) experienced MACE in 2.1% of cases (8/386), intermediate-risk (score 4-6) in 18.4% (68/370), and high-risk (score 7-10) in 48.5% (66/136). A HEART score ≤3 demonstrated 94.4% sensitivity and 65.7% specificity with negative predictive value of 97.9%. Conclusion: The HEART score demonstrates excellent discriminatory ability for predicting MACE in patients with undifferentiated chest pain, effectively identifying low-risk patients suitable for early discharge and outpatient management.Downloads
References
Amsterdam, E. A., Wenger, N. K., Brindis, R. G., et al. (2014). 2014 AHA/ACC guideline for the management of patients with non–ST-elevation acute coronary syndromes: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 64(24), e139–e228. https://doi.org/10.1016/j.jacc.2014.09.017
Hess, E. P., Brison, R. J., Perry, J. J., et al. (2012). Development of a clinical prediction rule for 30-day cardiac events in emergency department patients with chest pain and possible acute coronary syndrome. Annals of Emergency Medicine, 59(2), 115–125. https://doi.org/10.1016/j.annemergmed.2011.07.026
Pope, J. H., Aufderheide, T. P., Ruthazer, R., et al. (2000). Missed diagnoses of acute cardiac ischemia in the emergency department. New England Journal of Medicine, 342(16), 1163–1170. https://doi.org/10.1056/NEJM200004203421603
Goodacre, S., Cross, E., Arnold, J., et al. (2005). The health care burden of acute chest pain. Heart, 91(2), 229–230. https://doi.org/10.1136/hrt.2003.027599
Kohn, M. A., Kwan, E., Gupta, M., et al. (2005). Prevalence of acute myocardial infarction and other serious diagnoses in patients presenting to an urban emergency department with chest pain. Journal of Emergency Medicine, 29(4), 383–390. https://doi.org/10.1016/j.jemermed.2005.04.010
Owens, P. L., Barrett, M. L., Gibson, T. B., et al. (2010). Emergency department care in the United States: A profile of national data sources. Annals of Emergency Medicine, 56(2), 150–165. https://doi.org/10.1016/j.annemergmed.2009.11.022
Antman, E. M., Cohen, M., Bernink, P. J., et al. (2000). The TIMI risk score for unstable angina/non–ST elevation MI: A method for prognostication and therapeutic decision making. JAMA, 284(7), 835–842. https://doi.org/10.1001/jama.284.7.835
Hess, E. P., Agarwal, D., Chandra, S., et al. (2010). Diagnostic accuracy of the TIMI risk score in patients with chest pain in the emergency department: A meta-analysis. CMAJ, 182(10), 1039–1044. https://doi.org/10.1503/cmaj.092119
Six, A. J., Backus, B. E., & Kelder, J. C. (2008). Chest pain in the emergency room: Value of the HEART score. Netherlands Heart Journal, 16(6), 191–196. https://doi.org/10.1007/BF03086144
Backus, B. E., Six, A. J., Kelder, J. C., et al. (2010). Chest pain in the emergency room: A multicenter validation of the HEART score. Critical Pathways in Cardiology, 9(3), 164–169. https://doi.org/10.1097/HPC.0b013e3181ec36d8
Backus, B. E., Six, A. J., Kelder, J. C., et al. (2013). A prospective validation of the HEART score for chest pain patients at the emergency department. International Journal of Cardiology, 168(3), 2153–2158. https://doi.org/10.1016/j.ijcard.2013.01.255
Six, A. J., Cullen, L., Backus, B. E., et al. (2013). The HEART score for the assessment of patients with chest pain in the emergency department: A multinational validation study. Critical Pathways in Cardiology, 12(3), 121–126. https://doi.org/10.1097/HPC.0b013e31828b327e
Mahler, S. A., Riley, R. F., Hiestand, B. C., et al. (2015). The HEART Pathway randomized trial: Identifying emergency department patients with acute chest pain for early discharge. Circulation: Cardiovascular Quality and Outcomes, 8(2), 195–203. https://doi.org/10.1161/CIRCOUTCOMES.114.001384
Poldervaart, J. M., Langedijk, M., Backus, B. E., et al. (2017). Comparison of the GRACE, HEART and TIMI score to predict major adverse cardiac events in chest pain patients at the emergency department. International Journal of Cardiology, 227, 656–661. https://doi.org/10.1016/j.ijcard.2016.10.080
Van Den Berg, P., & Body, R. (2018). The HEART score for early rule out of acute coronary syndromes in the emergency department: A systematic review and meta-analysis. European Heart Journal: Acute Cardiovascular Care, 7(2), 111–119. https://doi.org/10.1177/2048872617710788
Laureano-Phillips, J., Robinson, R. D., Arber, S. A., et al. (2019). HEART score risk stratification of low-risk chest pain patients in the emergency department: A systematic review and meta-analysis. Annals of Emergency Medicine, 74(2), 187–203. https://doi.org/10.1016/j.annemergmed.2018.12.010
Fernando, S. M., Tran, A., Cheng, W., et al. (2019). Prognostic accuracy of the HEART score for prediction of major adverse cardiac events in patients presenting with chest pain: A systematic review and meta-analysis. Academic Emergency Medicine, 26(2), 140–151. https://doi.org/10.1111/acem.13649
Mahler, S. A., Hiestand, B. C., Goff, D. C., Jr., et al. (2011). Can the HEART score safely reduce stress testing and cardiac imaging in patients at low risk for major adverse cardiac events? Critical Pathways in Cardiology, 10(3), 128–133. https://doi.org/10.1097/HPC.0b013e3182315a85
