Chest pain: HEART pathway
HEART score with verified point definitions, 6-week MACE by category, and HEART Pathway disposition logic with serial troponin. It informs your clinical decision pathway and does not replace it.
1Does the pathway apply?
Tick anything present, or tick “None of these”. Any tick above “None” takes the patient off the HEART Pathway.
2History
3ECG
4Age
<45 → 0 · 45–64 → 1 · ≥65 → 2
5Risk factors
6Troponin
Initial troponin compared with your assay's 99th-percentile upper reference limit (URL).
Enter both to score T automatically.
How it works
HEART score definitions
| 0 | 1 | 2 | |
|---|---|---|---|
| History | Slightly suspicious | Moderately suspicious | Highly suspicious |
| ECG | Normal | Nonspecific repolarization (BBB, LVH, paced, digoxin, unchanged old changes) | Significant ST deviation not due to BBB/LVH/pacing/digoxin |
| Age | <45 | 45–64 | ≥65 |
| Risk factors | None | 1–2 | ≥3, or known atherosclerotic disease |
| Troponin | ≤ URL | >1 to 3× URL | >3× URL |
Risk factors: diagnosed hypertension, hypercholesterolemia and diabetes; current smoker or quit ≤3 months; family history (parent or sibling with CVD before 65); obesity (BMI >30). Atherosclerotic disease: prior MI, PCI/CABG, stroke/TIA or peripheral arterial disease. It scores 2 regardless of the number of risk factors.
The original score used a local, conventional troponin assay. Later validations scored 1 for 1–3× the limit and 2 for >3× (Six 2008, Mahler 2015). Exactly 3× scores 1. ECG scoring requires comparison with old tracings: if no prior ECG is available, treat abnormalities as new.
6-week MACE by category (Backus 2013)
Prospective validation in 10 Dutch hospitals, 2440 unselected ED chest pain patients. MACE was AMI, PCI, CABG or death within 6 weeks.
| HEART | Share of patients | 6-week MACE |
|---|---|---|
| 0–3 (low) | 36.4% | 1.7% |
| 4–6 (moderate) | — | 16.6% |
| 7–10 (high) | — | 50.1% |
A 1.7% miss rate is above the <1% 30-day death/MACE that the 2021 AHA/ACC guideline defines as low risk. That is why the score alone is not a discharge rule and serial troponin is added.
HEART Pathway (Mahler 2015, 2018)
- Low risk: HEART 0–3 and troponin ≤ 99th URL at 0 and 3 h. The pathway recommends discharge without stress testing or angiography, with primary-care follow-up. In the RCT (n = 282), 0 of the low-risk patients had MACE at 30 days, and early discharge rose from 18% to 40%.
- Not low risk: HEART ≥4, or any troponin above the 99th URL. The pathway recommends further in-hospital or observation evaluation. An elevated troponin or inducible ischemia triggers cardiology consultation and admission.
- Implementation (8474 patients, 3 US sites, 2018): known CAD or acute ischemic ECG changes made the patient non-low-risk regardless of score. 30.7% were low risk, and 0.4% of them had death or MI at 30 days. This tool applies that rule.
- Not eligible (trial exclusions): new ST elevation ≥1 mm, hypotension, life expectancy <1 year, or a noncardiac illness requiring admission. The trial enrolled patients aged ≥21.
High-sensitivity troponin
2021 AHA/ACC chest pain guideline: use clinical decision pathways (CDPs) routinely. hs-cTn is preferred. Low risk means a 30-day risk of death or MACE <1%. The HEART Pathway (HEART ≤3 with negative serial troponins) is one of the CDPs it lists. Repeat sampling is at 1–3 h for hs-cTn and 3–6 h for conventional assays.
2025 ACC/AHA ACS guideline: measure cTn as soon as possible, preferably hs-cTn (Class 1). If the first value is nondiagnostic, repeat at 1–2 h for hs-cTn and 3–6 h for conventional cTn (Class 1). For NSTE-ACS with refractory angina or hemodynamic or electrical instability, an immediate invasive strategy is indicated (Class 1).
With hs-cTn, "negative" means ruled out by your laboratory's validated 0/1-h or 0/2-h algorithm. These algorithms use assay-specific absolute thresholds and deltas, which a single 99th-percentile cut-off does not capture. A change between samples can be significant even when both values are below the URL.
Sources
- Six AJ, Backus BE, Kelder JC. Chest pain in the emergency room: value of the HEART score. Neth Heart J 2008;16:191–6. doi:10.1007/BF03086144
- Backus BE et al. A prospective validation of the HEART score for chest pain patients at the emergency department. Int J Cardiol 2013;168:2153–8. doi:10.1016/j.ijcard.2013.01.255
- Mahler SA et al. The HEART Pathway randomized trial: identifying emergency department patients with acute chest pain for early discharge. Circ Cardiovasc Qual Outcomes 2015;8:195–203. doi:10.1161/CIRCOUTCOMES.114.001384
- Mahler SA et al. Safely identifying emergency department patients with acute chest pain for early discharge (HEART Pathway implementation). Circulation 2018;138:2456–68. doi:10.1161/CIRCULATIONAHA.118.036528
- Brady W, de Souza K. The HEART score: a guide to its application in the emergency department. Turk J Emerg Med 2018;18:47–51. doi:10.1016/j.tjem.2018.04.004
- Gulati M et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain. Circulation 2021;144:e368–e454. doi:10.1161/CIR.0000000000001029
- Rao SV et al. 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes. Circulation 2025;151:e771–e862. doi:10.1161/CIR.0000000000001309
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