A metanalysis in 2019 showed the pooled sensitivity and specificity of the HEART score for predicting major adverse cardiac events (MACE) was 96% (95% CI 93%–98%) and 42.0% (95% CI 36%–49%) respectively. The positive predictive value (PPV) was 19% and negative predictive value (NPV) was 99%.15

A prospective study of 1748 patients compared GRACE, HEART and TIMI. The AUC of GRACE, HEART, and TIMI were 0.73 (95% CI: 0.70–0.76), 0.86 (95% CI 0.84–0.88) and 0.80 (95% CI 0.78–0.83) respectively (all differences in AUC were statistically significant).16 At an absolute level of safety of requiring at least 98% sensitivity, the GRACE score classified 231 patients as “low risk” with a missed MACE rate of 2.2%; the HEART score classified 381 patients as “low risk” with a missed MACE rate of 0.8%. The TIMI score identified no “low risk” patients at this safety level. A retrospective study compared EDACS and HEART scores in 118,822 patients and had a similar NPV of >99%,17 but EDACS identified a larger number of low-risk patients.18, 19

A prospective study of 519 patients in a Latin American population in which 224 patients (43%) had MACE at 30 days compared HEART, TIMI, and GRACE scores.20 The C statistic for the HEART, TIMI, and GRACE score was 0.937, 0.844, and 0.797 respectively (p<0.0001). A HEART score of 3 or less had a sensitivity of 99.5% and a negative predictive value of 99% to classify low risk patients correctly; both values were higher than those obtained by the other scores.17

The HEART Pathway in a randomised control trial by the creators was shown to increase early discharge by 21% compared to usual care without any missed cases of MACE.10 The EDACS ADP in its external validation study showed the pathway to have sensitivity and NPV of 100% and a specificity of 46.4%.14 A secondary analysis of data from a prospective observational study compared the diagnostic accuracy of HEART Pathway and EDACS-ADP when combined with 0h / 1h high sensitivity cardiac troponin protocol (hs-cTnt).17 When combined with 0-hour/1-hour hs-cTnT testing, the HEART Pathway and EDACS-ADP identified 49.8% and 49.6% of the patients for rule-out, with NPVs for 30-day MACE of 99.8% and 99.1%, compared with the HEART score alone that identified 53.4% of the patients for rule-out with NPV of 99.2%. The sensitivities of the HEART pathway, EDACS and the original HEART score were 99.1%, 96.7% and 96.7% respectively.