Prognostic Accuracy of the HEART Score in Predicting Major Adverse Cardiac Events: A Prospective Observational Study

BACKGROUND: Early diagnosis and effective risk stratification of patients presenting with chest pain who are at a high risk for adverse cardiac outcomes remain priorities in emergency departments (EDs). Major adverse cardiac events (MACE) in this context include myocardial infarction, death, and urgent revascularization procedures. The HEART score, comprising History, ECG, Age, Risk factors, and Troponin, was developed to facilitate rapid and reliable risk assessment. However, shortcomings in emergency care in India, such as limited access to advanced diagnostics and variability in clinical risk assessment, underscore the need for dependable tools validated in local settings. This study aims to address these gaps by providing prospective validation of the HEART score in an Indian tertiary care ED. OBJECTIVES: The primary objective was to assess the accuracy of the HEART score in predicting MACE within 30 days among adults presenting with chest pain (excluding ST-elevation myocardial infarction). Secondary objectives included evaluating the score's diagnostic validity in guiding clinical decision-making, improving patient disposition accuracy, and optimizing resource utilization, such as reducing unnecessary admissions and invasive testing in the ED setting. METHODS: The study was carried out at JSS Hospital's ED in Mysuru, India, from March to November 2022. We analyzed clinical data from 404 patients presenting to the ED with chest pain. Inter-observer variability was minimized by standardized training of clinicians performing the HEART score assessment. High-sensitivity troponin I assays (third generation) were employed to enhance reproducibility. The HEART score's predictive accuracy for MACE, defined as myocardial infarction, death, or urgent revascularization, within 30 days, was evaluated. RESULTS: Among 404 patients, 325 (80.4%) had low HEART scores (0-3) with a MACE incidence of 0.9% (3/325; p < 0.0001). Intermediate-risk patients (score 4-6) experienced MACE in 28.6% (16/56), while high-risk patients (score 7-10) had an MACE incidence of 89.2% (21/23) (p < 0.0001). These findings align with prior international validations, supporting the HEART score's utility in the Indian ED context. CONCLUSION: The HEART score enables effective, rapid risk stratification of chest pain patients, aiding clinical decision-making and potentially reducing unnecessary admissions, radiation exposure, and invasive procedures. This prospective study adds valuable evidence supporting the HEART score's applicability in Indian emergency care, addressing limitations in current risk assessment practices and resource constraints.