Use of the HEAR Score for 30-Day Risk-Stratification in Emergency Department Patients

Am J Med. 2023 Sep;136(9):918-926.e5. doi: 10.1016/j.amjmed.2023.04.041. Epub 2023 May 24.


Background: The 2021 American College of Cardiology/American Heart Association chest pain guidelines recommend risk scores such as HEAR (History, Electrocardiogram, Age, Risk factors) for short-term risk stratification, yet limited data exist integrating them with high-sensitivity cardiac troponin T (hs-cTnT).

Methods: Retrospective, multicenter (n = 2), observational, US cohort study of consecutive emergency department patients without ST-elevation myocardial infarction who had at least one hs-cTnT (limit of quantitation [LoQ] <6 ng/L, and sex-specific 99th percentiles of 10 ng/L for women and 15 ng/L for men) measurement on clinical indications in whom HEAR scores (0-8) were calculated. The composite major adverse cardiovascular event (MACE) outcome was 30-day prognosis.

Results: Among 1979 emergency department patients undergoing hs-cTnT measurement, 1045 (53%) were low risk (0-3), 914 (46%) intermediate risk (4-6), and 20 (1%) high risk (7-8) based on HEAR scores. HEAR scores were not associated with increased risk of 30-day MACE in adjusted analyses. Patients with quantifiable hs-cTnT (LoQ-99th) had an increased risk for 30-day MACE (3.4%) irrespective of HEAR scores. Those with serial hs-cTnT <99th percentile remained at low risk (range 0%-1.2%) across all HEAR score strata. Higher scores were not associated with long-term (2-year) events.

Conclusions: HEAR scores are of limited value in those with baseline hs-cTnT <LoQ or hs-cTnT >99th percentile to define short-term prognosis. In those with baseline quantifiable hs-cTnT within the reference range (<99th percentile), a higher risk (>1%) for 30-day MACE exists even in those with low HEAR scores. With serial hs-cTnT measurements, HEAR scores overestimate risk when hs-cTnT remains <99th percentile.

Keywords: High-sensitivity cardiac troponin; Major adverse cardiovascular events; Myocardial infarction; Myocardial injury; Risk stratification.

Publication types

  • Multicenter Study
  • Research Support, N.I.H., Extramural

MeSH terms

  • Biomarkers
  • Cohort Studies
  • Emergency Service, Hospital
  • Female
  • Humans
  • Male
  • Myocardial Infarction* / complications
  • Myocardial Infarction* / diagnosis
  • Predictive Value of Tests
  • Retrospective Studies
  • Troponin T


  • Biomarkers
  • Troponin T