Systematic review and meta-analysis of predictors of major adverse cardiac events among patients with chest pain and a low HEART score in the emergency department

Abstract

Background: The HEART score is widely used for rapid risk stratification of patients presenting to emergency departments with chest pain. However, a small proportion of patients classified as low risk (score ≤3) still experience major adverse cardiac events (MACE). This review evaluated the residual MACE risk and the diagnostic performance of the HEART score ≤3 threshold. Methods: A systematic review and meta-analysis was conducted using studies identified in PubMed and Embase from database inception to January 1, 2026. Eligible studies included adults (≥18 years) presenting with chest pain and reporting outcomes for a low HEART score group (0-3). Risk of bias was assessed using the Quality In Prognosis Studies tool. Random-effects models were used to pool event rates and diagnostic accuracy measures. Results: Five observational studies including 4,072 participants were included. The pooled MACE rate among low-risk patients was 0.56% [95% confidence interval (CI), 0.04%-1.52%]. The pooled sensitivity was 0.90, although individual study estimates ranged from 0.03 to 1.00. Specificity was 0.39 (95% CI, 0.31-0.46; I² = 90.6%), negative predictive value was 0.98 (95% CI, 0.27-1.00; I² = 93.9%), and positive predictive value was 0.05 (95% CI, 0.01-0.18; I² = 97.0%). A negative test reduced the modeled post-test probability of MACE to 4.9%. Conclusion: Although a HEART score ≤3 was associated with a low pooled MACE incidence, substantial between-study variability and imprecise diagnostic performance estimates limit reliance on the threshold as a stand-alone discharge criterion. The modeled post-test probability of 4.9% reinforces the need for broader clinical assessment, including appropriate troponin testing, before routine early discharge.