Key result
Low HEART score carries ~1% MACE rate but proves unreliable as a sole discharge criterion.
Why the study?
A small proportion of patients with chest pain classified as low risk by the HEART score (≤3) still experience major adverse cardiac events, and the diagnostic performance of this threshold is uncertain.
Does a HEART score ≤3 accurately predict a sufficiently low risk of major adverse cardiac events (MACE) in adult patients presenting to the emergency department with chest pain to allow for stand-alone early discharge?
Meta-Analysis (n=4,072)
Yes
Does a HEART score ≤3 accurately predict a sufficiently low risk of major adverse cardiac events (MACE) in adult patients presenting to the emergency department with chest pain to allow for stand-alone early discharge?
Effect estimate: 0.56% pooled event rate (95% CI 0.04-1.52)
Although a low HEART score (≤3) is associated with a very low pooled MACE incidence (0.56%), extreme between-study variability and a modeled post-test probability of 4.9% indicate it should not be used as a stand-alone discharge criterion without further clinical assessment and troponin testing.
Background: The HEART score is widely used for rapid risk stratification of patients presenting to emergency departments with chest pain. However, a small proportion of patients classified as low risk (score ≤3) still experience major adverse cardiac events (MACE). This review evaluated the residual MACE risk and the diagnostic performance of the HEART score ≤3 threshold. Methods: A systematic review and meta-analysis was conducted using studies identified in PubMed and Embase from database inception to January 1, 2026. Eligible studies included adults (≥18 years) presenting with chest pain and reporting outcomes for a low HEART score group (0-3). Risk of bias was assessed using the Quality In Prognosis Studies tool. Random-effects models were used to pool event rates and diagnostic accuracy measures. Results: Five observational studies including 4,072 participants were included. The pooled MACE rate among low-risk patients was 0.56% [95% confidence interval (CI), 0.04%-1.52%]. The pooled sensitivity was 0.90, although individual study estimates ranged from 0.03 to 1.00. Specificity was 0.39 (95% CI, 0.31-0.46; I² = 90.6%), negative predictive value was 0.98 (95% CI, 0.27-1.00; I² = 93.9%), and positive predictive value was 0.05 (95% CI, 0.01-0.18; I² = 97.0%). A negative test reduced the modeled post-test probability of MACE to 4.9%. Conclusion: Although a HEART score ≤3 was associated with a low pooled MACE incidence, substantial between-study variability and imprecise diagnostic performance estimates limit reliance on the threshold as a stand-alone discharge criterion. The modeled post-test probability of 4.9% reinforces the need for broader clinical assessment, including appropriate troponin testing, before routine early discharge.
No takes yet. Share an insight, caveat, or question.
Alruways et al. (2026) conducted a meta-analysis in Chest pain (n=4,072). HEART score ≤3 was evaluated on Pooled rate of major adverse cardiac events (MACE) (0.56% pooled event rate, 95% CI 0.04-1.52). A HEART score ≤3 was associated with a low pooled MACE incidence of 0.56%, but high between-study variability and a modeled negative post-test probability of 4.9% limit its utility as a stand-alone discharge criterion.
Synapse has enriched 5 closely related papers on similar clinical questions. Consider them for comparative context: