HEART Score Calculator for Major Cardiac Events
Calculate the HEART Score for chest pain risk stratification. Predicts 6-week MACE risk (death, MI, revascularization) in emergency department patients with undifferentiated chest pain.
HEART Score Assessment
Score each of the 5 HEART components (0, 1, or 2 points each)
Assess clinical suspicion based on presenting history. When in doubt, score higher for safety.
Score 2 requires ST deviation WITHOUT confounding factors. If attributable to LBBB, LVH, or digoxin, score = 1.
Patient age at presentation
Risk factors: hypertension, hypercholesterolemia, diabetes, obesity (BMI > 30), smoking (within 90 days), family history of CAD. Known atherosclerotic disease = automatic 2 points.
Use your institution's upper limit of normal (99th percentile). For hs-cTnT: typically 14 ng/L. For hs-cTnI: varies by assay.
Cardiovascular Risk Factors
Known atherosclerotic disease (prior MI, PCI/CABG, CVA/TIA, PAD) = automatic 2 points
HEART Score
Enter values to calculate
About This Calculator
The HEART Score is the most extensively validated risk stratification tool for undifferentiated chest pain in the emergency department. Developed by Six, Backus, and Kelder in the Netherlands in 2008, it uses 5 clinical components — History, ECG, Age, Risk factors, and Troponin — each scored 0-2, for a total of 0-10 points.
When to Use the HEART Score
The HEART Score is designed for patients presenting to the ED with chest pain where the diagnosis is uncertain. It answers the question: "Is this patient safe to discharge?" For patients with confirmed UA/NSTEMI, use the TIMI Score instead to guide management intensity.
Key Evidence
Over 30 validation studies with 40,000+ combined patients confirm a c-statistic of 0.83, significantly outperforming TIMI (0.75) and GRACE (0.70) in the ED setting. A HEART score of 0-3 carries a 6-week MACE rate of only 0.9-1.7%, with a negative predictive value of 99%.
HEART Pathway
The HEART Pathway adds serial troponin measurements at 0h and 3h. If HEART score is 0-3 AND both troponins are negative, the NPV approaches 100%, providing the strongest evidence for safe early discharge.
2022 ACC Expert Consensus
The 2022 ACC pathway recommends the modified HEART score (HEAR, omitting Troponin) for risk stratification after MI has been ruled out by high-sensitivity troponin. In institutions with hs-cTn, the troponin pathway itself drives disposition, and routine risk score application is not recommended.
Formula
HEART Score = History + ECG + Age + Risk Factors + Troponin (each 0-2, total 0-10)Each of the 5 HEART components scores 0, 1, or 2 points (maximum 10): • **H**istory: Clinical suspicion from presenting symptoms (0 = slightly suspicious, 1 = moderately suspicious, 2 = highly suspicious) • **E**CG: Electrocardiogram findings (0 = normal, 1 = non-specific changes, 2 = significant ST deviation) • **A**ge: Patient age (0 = < 45, 1 = 45-64, 2 = ≥ 65) • **R**isk Factors: Cardiovascular risk factors (0 = none, 1 = 1-2, 2 = ≥ 3 or known atherosclerotic disease) • **T**roponin: Cardiac biomarker level (0 = ≤ normal, 1 = 1-3× normal, 2 = > 3× normal)
Clinical Considerations
- •The HEART Score is for undifferentiated chest pain — NOT for confirmed STEMI or clearly non-cardiac chest pain
- •The History component is subjective (70% discordance between EPs and cardiologists). When in doubt, score higher.
- •A score of 3 is a borderline zone — some studies show 2-4% MACE risk. Consider serial troponins for score 3.
- •Troponin thresholds depend on your institution's assay. Use your lab's 99th percentile as the "normal limit."
- •Known atherosclerotic disease (prior MI, PCI/CABG, CVA/TIA, PAD) = automatic Risk Factor score of 2
- •With high-sensitivity troponin, the 2022 ACC recommends hs-cTn pathways over routine HEART scoring for disposition
Limitations
- •Subjective History and ECG components affect inter-rater reliability (ICC 0.78)
- •Initial troponin may be negative if presentation is early (< 3-6 hours from symptom onset)
- •Original validation used conventional troponin — hs-cTn may require recalibrated thresholds
- •Not validated for ST-elevation MI (STEMI)
- •Does not account for non-ACS causes of troponin elevation (PE, myocarditis, renal failure)
- •Risk factor definitions vary across implementations (obesity inclusion, smoking cessation timeframe)
- •Does not incorporate hemodynamic parameters or Killip class
- •C-statistic of 0.83 means the score is imperfect — clinical judgment must always supplement
Interpretation Guide
| Range | Classification | Recommendation |
|---|---|---|
| <-3 | Low Risk | Low risk for major adverse cardiac events. Consider early discharge with outpatient follow-up within 72 hours. Serial troponins (HEART Pathway) may provide additional safety for borderline cases. |
| 3-6 | Moderate Risk | Moderate risk. Admit for observation. Further cardiac testing recommended (stress test, CT coronary angiography, or serial troponins). Cardiology consultation advised. |
| 6-11 | High Risk | High risk. Hospital admission required. Urgent cardiology consultation and early invasive strategy recommended. Initiate guideline-directed medical therapy for ACS. |
Frequently Asked Questions
What is the HEART Score?
The HEART Score is a clinical prediction tool that stratifies risk of major adverse cardiac events (MACE) in emergency department patients with undifferentiated chest pain. It scores 5 components — History, ECG, Age, Risk factors, and Troponin — each 0-2 points, for a total of 0-10. It was developed in the Netherlands in 2008 and validated in over 40,000 patients.
What does HEART score stand for?
HEART is an acronym for the 5 components: History (clinical suspicion of ACS), ECG (electrocardiogram findings), Age, Risk factors (cardiovascular risk factors), and Troponin (cardiac biomarker level). Each component scores 0, 1, or 2 points.
What HEART score is safe to discharge?
A HEART score of 0-3 is classified as low risk with a 6-week MACE rate of only 0.9-1.7% and an NPV of 99%. These patients may be considered for early discharge with close outpatient follow-up. The HEART Pathway (adding serial troponins at 0h and 3h) further strengthens the safety of discharge for scores 0-3.
What are the 5 components of the HEART Score?
The 5 components are: (1) History — clinical suspicion level of ACS based on symptoms, (2) ECG — normal, non-specific changes, or significant ST deviation, (3) Age — under 45, 45-64, or 65+, (4) Risk Factors — number of cardiovascular risk factors or known atherosclerotic disease, (5) Troponin — normal, 1-3x elevated, or >3x elevated.
What is the difference between HEART score and TIMI score?
The HEART Score is for undifferentiated ED chest pain (Is this ACS? Safe to discharge?), while TIMI is for confirmed UA/NSTEMI (How aggressively should we treat?). HEART uses 5 graded components (0-10 total) and predicts 6-week MACE. TIMI uses 7 binary factors (0-7 total) and predicts 14-day events. HEART outperforms TIMI in the ED with a c-statistic of 0.83 vs 0.75.
What is the HEART Pathway?
The HEART Pathway combines the HEART Score with serial troponin measurements at 0 and 3 hours. If the HEART score is 0-3 AND both troponins are negative, the NPV approaches 100%, providing the strongest evidence for safe early discharge. It was validated in a randomized trial (Mahler 2015) showing 21% more early discharges with no adverse outcomes.
Does the HEART score work with high-sensitivity troponin?
The original HEART Score was validated with conventional troponin. With high-sensitivity troponin (hs-cTn), the troponin component thresholds should use your institution's 99th percentile as the "normal limit" (e.g., hs-cTnT: 14 ng/L). The 2022 ACC recommends hs-cTn accelerated pathways over routine HEART scoring when hs-cTn is available.
What are the risk factors in the HEART score?
The 6 recognized risk factors are: hypertension, hypercholesterolemia, diabetes mellitus, obesity (BMI > 30), current smoking or cessation within 90 days, and family history of coronary artery disease. Additionally, history of atherosclerotic disease (prior MI, PCI/CABG, CVA/TIA, or PAD) automatically scores 2 points regardless of other risk factors.
How accurate is the HEART Score?
The HEART Score has a pooled c-statistic of 0.83, sensitivity of 96%, and NPV of 99% for low-risk scores (0-3). In over 30 validation studies with 40,000+ patients, it consistently outperforms TIMI (c=0.75) and GRACE (c=0.70) for ED chest pain risk stratification.
Can nurses use the HEART Score?
Yes. The HEART Score is designed for use by any trained clinician including nurses, PAs, NPs, and physicians. However, the History and ECG components require clinical judgment, and inter-rater reliability varies. PAs and NPs frequently use it for disposition documentation. Some studies show ambulance nurses may underestimate the History and Risk Factor components.
References
1. Six AJ, Backus BE, Kelder JC. Chest pain in the emergency room: value of the HEART score. Netherlands Heart Journal. 2008
View Source →2. Backus BE, Six AJ, Kelder JC, et al.. A prospective validation of the HEART score for chest pain patients at the emergency department. International Journal of Cardiology. 2013. doi: 10.1016/j.ijcard.2013.01.255
View Source →3. Mahler SA, Riley RF, Hiestand BC, et al.. The HEART Pathway randomized trial: identifying emergency department patients with acute chest pain for early discharge. Circulation: Cardiovascular Quality and Outcomes. 2015. doi: 10.1161/CIRCOUTCOMES.114.001384
View Source →4. Poldervaart JM, Reitsma JB, Backus BE, et al.. Effect of using the HEART score in patients with chest pain in the emergency department: a stepped-wedge, cluster randomized trial. Annals of Internal Medicine. 2017. doi: 10.7326/M16-1600
View Source →5. Kontos MC, de Lemos JA, Deitelzweig SB, et al.. 2022 ACC Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department. Journal of the American College of Cardiology. 2022. doi: 10.1016/j.jacc.2022.08.750
View Source →Last updated: 2026-02-24
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