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Chest Pain Workup

HEART score plus the ESC 0/1-hour high-sensitivity troponin algorithm, combined into one disposition, with the published miss rate of each pathway.

Not for patients with ST elevation meeting STEMI criteria, hemodynamic instability, or ongoing pain despite treatment. They need immediate management, not risk stratification.

HEART score

History 0

ECG 0

Age 0

Risk factors 0

Hypertension Hypercholesterolemia Diabetes Obesity (BMI > 30) Smoking (current or quit ≤ 3 mo) Family history (parent/sibling CVD < 65) Known atherosclerotic disease (prior MI, PCI/CABG, stroke/TIA, PAD), scores 2 on its own

Troponin (from the 0 h value below) –

Enter the 0 h troponin.

High-sensitivity troponin

Assay

0 h (ng/L)

1 h (ng/L, optional)

99th percentile URL (ng/L)

Pain onset before 0 h draw

Cutoffs are the assay-specific values from the ESC ACS guideline. The URL sets the HEART troponin points and is overall (not sex-specific); use your lab's value.

Result

–HEART

ESC 0/1 h: –

Enter troponin values.

Disposition

Complete the inputs above.

How often each pathway misses

Pathway	Low-risk group	Outcome in low-risk group
HEART score alone	0–3	1.7% MACE at 6 wk
HEART Pathway	0–3 + negative 0 h & 3 h troponin	0.4% death/MI at 30 d
ESC 0/1 h hs-troponin	Rule-out zone	NPV > 99.5% for MI
ESC 0/1 h hs-troponin	Rule-in zone	PPV ≈ 70–75% for MI

MACE = death, MI, or coronary revascularization. HEART 4–6: 16.6%; 7–10: 50.1% (Backus 2013).

Sources

Six AJ et al. Chest pain in the emergency room: value of the HEART score. Neth Heart J 2008;16:191–6.
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.
Mahler SA et al. Safely identifying emergency department patients with acute chest pain for early discharge (HEART Pathway). Circulation 2018;138:2456–68.
Byrne RA et al. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J 2023;44:3720–826.
Gulati M et al. 2021 AHA/ACC guideline for the evaluation and diagnosis of chest pain. Circulation 2021;144:e368–454.

Teaching and decision support only. It does not replace clinical judgment or your institution's protocol.