A Methodological Appraisal of the HEART Score and Its Variants

Ann Emerg Med. 2021 Aug;78(2):253-266. doi: 10.1016/j.annemergmed.2021.02.007. Epub 2021 Apr 29.


We performed a methodological appraisal of the history, electrocardiogram, age, risk factors, and troponin (HEART) score and its variants in the context of Annals of Emergency Medicine's methodological standards for clinical decision rules. We note that this chest pain risk stratification tool was not formally derived, omits sex and other known predictors, has weak interrater reliability, and its 0, 1, and 2 score weightings do not align with their known predictivities. Its summary performance (pooled sensitivities of 96% to 97% with lower confidence interval bounds of 93% to 94%) is below that which emergency physicians state a willingness to accept, below the 98% sensitivity exhibited by baseline practice without the score, and below the 1% to 2% acceptable miss threshold specified by the American College of Emergency Physicians chest pain policy. Two variants (HEART Pathway, HEART-2) have the same inherent structural limitations and demonstrate slightly better but still suboptimal sensitivity. Although a simple prediction tool for chest pain outcomes is appealing, we believe that the widespread use of the HEART score and its variants should be reconsidered.

Publication types

  • Evaluation Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Aged
  • Chest Pain / diagnosis*
  • Clinical Decision Rules*
  • Female
  • Heart Diseases / diagnosis*
  • Humans
  • Male
  • Middle Aged
  • Observer Variation
  • Reproducibility of Results
  • Risk Assessment
  • Sensitivity and Specificity