HEART Score Distribution and Association with In-Hospital Management and Outcomes in COVID-19 Survivors Presenting with Acute Chest Pain

Background: Acute chest pain is a common cause for presentation to the emergency department (ED), where rapid identification of patients at high risk for acute coronary syndrome is essential. The HEART score combines medical history, electrocardiogram, age, risk factors, and troponin levels to provide structured risk stratification. However, evidence regarding the HEART score in COVID-19 survivors presenting with acute chest pain remains limited. This study examined the distribution of HEART scores and their associations with decisions made in the emergency department, hospital management, rises in cardiac troponin levels, coronary revascularization, and in-hospital mortality. Materials and Methods: In this single-center retrospective observational study, 400 consecutive adult COVID-19 survivors who presented to the ED with acute non-traumatic chest pain were included. HEART scores were retrospectively calculated from routinely available clinical and laboratory data, and patients were categorized as low (0–3), moderate (4–6), or high risk (7–10). Results: The median HEART score was 2 (IQR 0–5); 264 patients (66.0%) were classified as low risk, 50 (12.5%) as moderate risk and 86 (21.5%) as high risk. The distribution of the total score was bimodal, with 128 patients (32.0%) scoring zero and 78 (19.5%) scoring 8–10. Cardiac troponin was above the upper reference limit at presentation or at one hour in 96 patients (24.0%): 3 of 264 low-risk patients (1.1%), 7 of 50 moderate-risk patients (14.0%) and all 86 high-risk patients (100%). Eighty-three patients (20.8%) were admitted to hospital, almost all from the high-risk category (82 of 86, 95.3%), compared with 1 of 50 moderate-risk patients (2.0%) and no low-risk patient. All 51 revascularisation procedures (46 percutaneous coronary interventions and 5 coronary artery bypass grafts) and all five in-hospital deaths (1.2% of the cohort) occurred among high-risk patients. In an exploratory, hypothesis-generating multivariable analysis of troponin elevation, older age (adjusted odds ratio 2.38 per decade, 95% CI 1.88–3.09) and smoking (4.10, 2.12–8.06) were associated with elevation and female sex was inversely so (0.22, 0.11–0.41); renal function was not available for adjustment. Conclusions: HEART score categories were associated with ED disposition and in-hospital management in this retrospective cohort of COVID-19 survivors presenting with acute chest pain. High-risk patients accounted for nearly all hospital admissions, coronary revascularizations, and in-hospital deaths. However, systematic post-discharge follow-up was not available; therefore, 30-day or 6-week MACE could not be assessed, and the prognostic performance of the HEART score or the safety of HEART-based discharge cannot be determined. These findings should therefore be interpreted as descriptive associations reflecting real-world clinical practice and warrant confirmation in prospective studies with systematic follow-up.