What HEART score is safe for discharge?

A HEART score of 0–3 is classified as low risk, with a 6-week major adverse cardiac event (MACE) rate below 2%. These patients can be safely discharged from the emergency department with outpatient cardiology follow-up, provided their initial and serial troponins are negative.

What does HEART stand for in the HEART score?

HEART is an acronym for the five variables: History (chest pain characteristics), ECG findings, Age, Risk factors for coronary artery disease, and Troponin level. Each component is scored 0–2, giving a maximum total of 10.

HEART Score calculator

How to use it

1
Assess history. Highly suspicious: pressure, radiation, exertional, nitrate relief. Slightly suspicious: pleuritic, well-localised.
2
Review ECG. Normal=0, non-specific (LVH, LBBB, repol changes)=1, significant ST deviation=2.
3
Troponin relative to URL. Use the lab's 99th percentile upper reference limit. hsTnI/hsTnT ×1–3=1pt, >3×=2pt.

When to use it

Apply to all patients presenting to the emergency department with acute chest pain where ACS must be excluded. Particularly useful for the large proportion of chest pain presentations that are ultimately non-cardiac.

Acute chest pain ED triage: Score ≤3 supports discharge without further investigation.
0/3h troponin protocols: Pair with 0h and 3h hsTn for rapid rule-out (ESC 2020 pathway).
Not for STEMI: STEMI goes straight to cath lab regardless of HEART score.

About the score

The HEART score is a validated 5-variable risk stratification tool for patients presenting to the emergency department with chest pain of possible cardiac origin. Each of the five components — History, ECG, Age, Risk factors, and Troponin — is scored 0, 1, or 2, giving a maximum of 10 points. Low-risk patients (HEART score 0–3) have a very low 6-week MACE rate (<2%) and can be safely discharged from the emergency department without admission, significantly reducing unnecessary hospitalisation. High-risk patients (score 7–10) require urgent cardiological referral and admission.

History, ECG, Age, Risk factors, Troponin

Scoring criteria

History (highly suspicious / moderately suspicious / slightly suspicious)Highly suspicious: typical ACS features (chest pressure, radiation, diaphoresis). Slightly suspicious: non-specific or atypical features.: 2 / 1 / 0
ECG (significant ST deviation / non-specific repolarisation disturbance / normal)LBBB, LVH and a paced rhythm count as non-specific repolarisation disturbance (1 point).: 2 / 1 / 0
Age (≥65 / 45–64 / <45): 2 / 1 / 0
Risk factors (≥3 or known atherosclerotic disease / 1–2 risk factors / none)Risk factors: hypertension, diabetes, hypercholesterolaemia, obesity, smoking, family history of CAD: 2 / 1 / 0
Troponin (>3× normal / 1–3× normal / normal): 2 / 1 / 0

Score interpretation

0–3Low riskMACE risk <2% at 6 weeks; safe early discharge; outpatient follow-up
4–6Moderate riskMACE risk ~12–17%; admit for observation and further testing
7–10High riskMACE risk ~50–65%; urgent cardiology referral; early invasive strategy

Guideline recommendation

ESC 2023 ACS Guidelines endorse validated risk scores (including HEART) as adjuncts to the 0h/1h high-sensitivity troponin pathway for chest pain risk stratification. Low HEART score + negative hs-cTnI at 0h supports safe discharge.

ESC 2023Acute Coronary Syndromes 2023

Clinical pearls

The HEART score is best used alongside the ESC 0h/1h high-sensitivity troponin algorithm — together they identify a large "rule-out" population for safe ED discharge.
Serial troponin (0h and 1h or 2h) is central to HEART scoring — the troponin component carries significant weight.
A score of 0–3 with negative serial troponins supports early discharge, but the score never overrides a strong clinical suspicion of ACS.
Do not use in STEMI or haemodynamically unstable patients — these require immediate intervention regardless of HEART score.

Limitations

The "History" component introduces subjective clinical assessment.
Requires high-sensitivity troponin assays for optimal accuracy.
Not validated as a standalone tool in patients with STEMI or suspected type 2 MI (demand ischaemia).

HEART Score for Chest Pain