Healthcare practitioners' use of the HEART score for risk stratification and management of adults with acute chest pain presenting to the emergency department: A scoping review

BACKGROUND: Chest pain is one of the most common reasons for visits to the Emergency Department (ED) worldwide. Effective risk stratification tools are essential for distinguishing between life-threatening cardiac events and non-cardiac causes. The HEART score is a widely used clinical decision tool designed to assist in this process. This review aims to synthesise the evidence on healthcare practitioners' use of the HEART score for risk stratification and management of adults with acute chest pain presenting to the ED. METHODS: A scoping review methodology, based on the Joanne Briggs Institute (JBI) framework, was employed. The review is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis for Scoping Reviews (PRISMA-ScR). The Population - Concept - Context (PCC) framework was used to inform the development of the research question and the inclusion and exclusion criteria. Six electronic databases (CINAHL, Medline, SCOPUS, PubMed, Embase, and GreyLit) were searched from January 2015 to January 2025. Screening was conducted independently by two reviewers against eligibility criteria, with regular meetings held to resolve issues and reach consensus. Data were extracted on study characteristics, use of the HEART score, methodology, patient outcomes and key findings. FINDINGS: Fifteen studies from seven countries were included, encompassing a range of study designs and large variability in sample size. The HEART score demonstrates high inter-operator reliability, with the strongest agreement observed in objective components such as age and troponin levels, and comparatively lower agreement in more subjective elements, particularly patient history. In addition, the HEART score shows strong predictive performance for major adverse cardiac events (MACE), with consistently low event rates (0-2%) among low-risk patients and substantially higher rates observed in intermediate and high-risk groups. High sensitivity supports its safety in identifying patients suitable for early discharge. However, variation in clinician adherence was evident, with low-risk patients frequently admitted despite minimal MACE incidence. Implementation of the HEART pathway was associated with reductions in hospitalisations and diagnostic testing without compromising patient outcomes, highlighting its value in optimising ED utilisation. CONCLUSION: The HEART score is a reliable and effective risk assessment tool for assessing patients with chest pain in the ED. It demonstrates strong predictive accuracy for adverse cardiac events and supports improved patient flow. However, variability in clinician adherence, particularly among less experienced practitioners, may limit its full potential. Enhancing education, supporting clinical decision-making, and integrating the HEART score into clinical structured care pathways may optimise its use and improve patient outcomes.