Heart Score for Major Cardiac Events

Understanding the HEART Score for Major Adverse Cardiac Events (MACE)

The HEART Score is a clinical tool used to estimate the risk of major adverse cardiac events (MACE) within six weeks in patients presenting with chest pain suggestive of acute coronary syndrome (ACS). It is based on five key elements—History, EKG, Age, Risk Factors, and Initial Troponin—which form the acronym “HEART.”

Components of the HEART Score

History

• 0 points: Slightly suspicious symptoms (e.g., localized or sharp pain, non-exertional, no diaphoresis or nausea/vomiting, reproducible with palpation).
• 1 point: Moderately suspicious (e.g., retrosternal pressure with some, but not all, classic anginal features).
• 2 points: Highly suspicious (e.g., typical anginal pain—pressure or tightness behind the sternum, radiating to the jaw or arm, provoked by exertion, relieved by nitrates).

EKG

• 0 points: Normal tracing (no ST changes, no new abnormalities).
• 1 point: Non-specific repolarization disturbances (e.g., LBBB, LVH, changes attributed to digoxin).
• 2 points: Significant ST deviation that is new or acute, not explained by LBBB, LVH, or digoxin effect.

Age

• 0 points: Younger than 45 years.
• 1 point: Between 45 and 64 years.
• 2 points: 65 years or older.

Risk Factors

• 0 points: No traditional cardiovascular risk factors.
• 1 point: One or two factors (e.g., hypertension, hypercholesterolemia, diabetes, obesity, current or recent smoking, positive family history).
• 2 points: Three or more risk factors, or a known history of atherosclerotic disease (prior MI, PCI/CABG, stroke/TIA, peripheral arterial disease).

Initial Troponin

• 0 points: Within normal limits.
• 1 point: Elevated at 1–3 times the normal limit.
• 2 points: Greater than three times the normal limit.

Scoring Method

For each category—History, EKG, Age, Risk Factors, and Initial Troponin—assign points according to the criteria above. The final HEART Score is the sum of these individual point values:

Interpretation and MACE Risk

• Total Score 0–3 (Low Risk): Approximately 1–2% risk of experiencing a major adverse cardiac event within six weeks.
• Total Score 4–6 (Moderate Risk): Around 12–16% risk of a MACE.
• Total Score 7–10 (High Risk): Between 50–65% risk of a MACE.

These percentages may vary slightly based on the patient population or local protocols.

Clinical Application and Considerations

The HEART Score applies to adults (≥21 years old) who present with chest pain suspicious for ACS, without confounding factors such as new ST elevation ≥1 mm, severe hypotension, or a primary non-cardiac medical or surgical issue requiring admission.

• Low Risk (0–3): Often appropriate for early discharge, outpatient follow-up, or additional testing (e.g., stress testing) if warranted.
• Moderate Risk (4–6): May benefit from hospital observation, serial troponin measurements, and/or advanced cardiac testing.
• High Risk (7–10): Typically requires urgent or inpatient evaluation, possible cardiology consultation, and consideration for invasive testing such as angiography.

It is important to remember that the HEART Score does not replace clinical judgment. Providers should interpret the score in the context of the patient’s overall clinical picture and use additional diagnostic measures when necessary.

Summary

• The HEART Score aids in classifying patients with suspected ACS by their short-term MACE risk.
• It relies on five simple elements: History, EKG, Age, Risk Factors, and Troponin.
• Scores of 0–3 generally indicate low risk, 4–6 suggest moderate risk, and 7–10 represent high risk.
• Clinical assessment remains paramount—if patient presentation is atypical or concerning, additional investigation may be warranted even with a lower score.

Disclaimer
The HEART Score is designed to assist, not replace, a thorough clinical evaluation. Use it alongside clinical judgment, additional diagnostic tests, and local practice standards to guide patient care decisions.