How this instrument works
History, ECG, Age, Risk factors, and Troponin — each category runs 0, 1, or 2, for a total between 0 and 10. History covers how strongly the presenting story — location, character, radiation, associated symptoms — fits classic cardiac chest pain, scored on clinical impression rather than a checklist. ECG scores normal as 0, a nonspecific repolarization disturbance as 1, and significant ST deviation as 2. Age steps up at 45 and 65. Risk factors — hypertension, high cholesterol, diabetes, obesity, smoking, a family history, or known atherosclerotic disease — score 0 for none, 1 for one or two, and 2 for three or more, or for any known atherosclerotic disease regardless of count. Troponin scores by multiples of the local upper reference limit: at or below it, one to three times it, or over three times it.
Six and colleagues published it in 2008 after testing it on patients presenting to a Dutch emergency department with chest pain, splitting the resulting totals into three bands: 0-3 low risk, with roughly a 1-to-2 percent chance of a major adverse cardiac event within six weeks; 4-6 moderate risk, around 12 to 17 percent; and 7-10 high risk, 50 to 65 percent. Those bands are wide enough to change what happens next — a low result supports early discharge, a high one supports admission and further workup, and the moderate band is where most of the harder judgment calls live.
The inclusion of History as its own scored category sets HEART apart from most instruments on this site, which stick to objective findings a machine could in principle tally. HEART's authors deliberately built in room for the clinician's overall gestalt — the sense an experienced physician forms from tone, pattern recognition, and everything a checklist alone won't capture — on the reasoning that this judgment genuinely adds predictive value on top of the objective findings, not instead of them. That's also an acknowledged limitation: the same patient can score differently under two different examiners, which is why the tool is meant to support a decision, not replace one.
- Rate History as slightly, moderately, or highly suspicious for cardiac chest pain, based on clinical impression.
- Rate the ECG as normal, showing a nonspecific repolarization disturbance, or showing significant ST deviation.
- Select the Age band: under 45, 45-64, or 65 and older.
- Select Risk factors: none known, 1-2, or 3 or more (or known atherosclerotic disease).
- Select the initial Troponin level relative to the upper reference limit, then read the total and its risk band.
Worked example — highly suspicious history, elevated troponin
A patient with a story highly suspicious for cardiac chest pain, a nonspecific ECG change, age 68, two known risk factors plus documented atherosclerotic disease, and a troponin running 1 to 3 times the upper reference limit. That's History (2) + ECG (1) + Age (2) + Risk factors (2) + Troponin (1) = 8.
A total of 8 lands in the high-risk band (7-10), where the original validation reported a 50-to-65 percent chance of a major cardiac event within six weeks. That's a very different conversation than a total of 3 — the two scenarios can share an identical ECG and troponin and still land in different bands purely because of what the physician heard in the history.
Questions
Why does the physician's impression get a score at all?
Because HEART's authors found that clinical gestalt — the pattern an experienced clinician recognizes from the full story, not any single data point — predicted outcomes on its own, and combining it with objective findings outperformed either alone. It's the category most open to disagreement between examiners, a real limitation, but the original validation showed it earns its place in the total.
What's the difference between the three risk bands?
Low risk (0-3) carries roughly a 1-to-2 percent chance of a major cardiac event within six weeks and generally supports early discharge; moderate (4-6) runs 12 to 17 percent and usually prompts further testing or observation; high (7-10) runs 50 to 65 percent and typically means admission and urgent workup. The bands come from the original Dutch cohort published in 2008.
How is Age scored?
Zero points under 45, one point from 45 to 64, two points at 65 or older. It's a coarse three-band split rather than a continuous formula, which keeps the score fast to calculate at the bedside.
Does a known risk factor like smoking count the same as one like family history?
Yes — the category simply counts how many of the standard cardiac risk factors (hypertension, high cholesterol, diabetes, obesity, smoking, and family history) are present, plus a flag for any known atherosclerotic disease, and scores by that count: none, one or two, or three or more. It doesn't weigh one factor as worse than another.
Can a patient score 0 on History and still have a heart attack?
It's uncommon but not impossible, which is exactly why HEART sums five categories instead of relying on any one of them. A very low total across all five components is what the derivation cohort tied to roughly a 1-to-2 percent event rate — reassuring, not risk-free, and still meant to sit alongside clinical judgment rather than substitute for it.
Who is this score meant for?
Emergency clinicians evaluating adults presenting with chest pain where the working concern is a possible acute coronary event — it was derived and validated in that emergency-department population specifically, not for chest pain with an obvious non-cardiac cause or for patients already diagnosed with a STEMI, who move straight to reperfusion pathways regardless of any score.
References
- Six AJ, Backus BE, Kelder JC — Neth Heart J, 2008 (PubMed)
- Gulati M, Levy PD, Mukherjee D, et al. — 2021 AHA/ACC Chest Pain Guideline, Circulation (PubMed)
Read this first: This instrument computes a screening figure from population formulas — it is not a diagnosis, and it cannot see the whole picture a clinician can. Use it to inform a conversation, not to replace one.