The HEART score for early rule out of acute coronary syndromes in the emergency department: a systematic review and meta-analysis

Aims: The objective of this systematic review was to summarise the current evidence on the diagnostic accuracy of the HEART score for predicting major adverse cardiac events in patients presenting with undifferentiated chest pain to the emergency department. Methods and results: Two investigators independently searched Medline, Embase and Cochrane databases between 2008 and May 2016 identifying eligible studies providing diagnostic accuracy data on the HEART score for predicting major adverse cardiac events as the primary outcome. For the 12 studies meeting inclusion criteria, study characteristics and diagnostic accuracy measures were systematically extracted and study quality assessed using the QUADAS-2 tool. After quality assessment, nine studies including data from 11,217 patients were combined in the meta-analysis applying a generalised linear mixed model approach with random effects assumption (Stata 13.1). In total, 15.4% of patients (range 7.3–29.1%) developed major adverse cardiac events after a mean of 6 weeks’ follow-up. Among patients categorised as ‘low risk’ and suitable for early discharge (HEART score 0–3), the pooled incidence of ‘missed’ major adverse cardiac events was 1.6%. The pooled sensitivity and specificity of the HEART score for predicting major adverse cardiac events were 96.7% (95% confidence interval (CI) 94.0–98.2%) and 47.0% (95% CI 41.0–53.5%), respectively. Conclusions: Patients with a HEART score of 0–3 are at low risk of incident major adverse cardiac events. As 3.3% of patients with major adverse cardiac events are ‘missed’ by the HEART score, clinicians must ask whether this risk is acceptably low for clinical implementation.