Key result
HEAR score <2 safely rules out 45-day MACE without troponin, showing ~100% negative predictive value.
Why the study?
Current diagnostic strategies for chest pain in the emergency department rely heavily on troponin testing, but a new clinical tool, the HEAR score, requiring no blood sampling, has been proposed to identify low-risk patients.
Does a HEAR score < 2 safely identify emergency department patients with chest pain at low risk for short-term MACE without requiring troponin testing?
Cohort (n=1,807)
No
Does a HEAR score < 2 safely identify emergency department patients with chest pain at low risk for short-term MACE without requiring troponin testing?
The HEAR score successfully identified a subset of emergency department chest pain patients (36%) at very low risk for 45-day MACE with a 100% negative predictive value, suggesting utility for early risk stratification without troponin testing.
May support troponin-free ED evaluation of low-risk chest pain by HEAR score; leaves open prospective validation before practice change.
BACKGROUND: Chest pain is a frequent reason for Emergency Department (ED) visits, although only a minority of patients ultimately present an Acute Coronary Syndrome (ACS). Current diagnostic strategies rely heavily on troponin testing, but a new clinical tool requiring no blood sampling, the HEAR score, has recently been proposed. This study aimed to evaluate the performance of the HEAR score for identifying low-risk patients presenting with chest pain, using 45-day Major Adverse Cardiovascular Events (MACE) as the primary outcome. METHODS: All patients presenting with chest pain to the ED of Dijon University Hospital in 2019 were retrospectively analyzed in this single-center study. Patients were stratified as "low risk" (HEAR < 2) or "high risk" (HEAR ≥ 2). Outcomes assessed at 45-days included MACE (defined as a composite of all-cause death, non-fatal myocardial infarction, and urgent coronary revascularization) and recurrence of ED consultation for chest pain. RESULTS: Among 2177 patients presenting with chest pain, 1807 met inclusion criteria. Of these, 653 (36%) were classified as low risk (HEAR < 2). At 45-days, 22 (3%) low-risk patients reconsulted for chest pain compared with 64 (6%) in the high-risk group (p = 0.037). No MACE was identified among low-risk patients within the available follow-up data. The negative predictive value of a HEAR score < 2 was 100% (95% CI: 99.5%-100%), with an upper 95% confidence bound for the event rate of 0.46%. CONCLUSION: A HEAR score < 2 identifies a substantial proportion of ED chest pain patients at very low risk of short-term adverse cardiovascular events. However, given the limitations of retrospective follow-up and potential under-ascertainment of events, these findings should be considered hypothesis-generating. The HEAR score may contribute to early clinical risk stratification rather than replace troponin-based strategies.
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Pommier et al. (2026) conducted a cohort in Chest pain (n=1,807). HEAR score < 2 vs. HEAR score ≥ 2 was evaluated on 45-day Major Adverse Cardiovascular Events (MACE) (NPV 100%, 95% CI 99.5%-100%). A HEAR score < 2 for ED patients with chest pain yielded a 100% negative predictive value (95% CI 99.5%-100%) for 45-day MACE, identifying patients at very low risk without troponin testing.
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