The most thought-provoking finding from the study was that, despite the guidance offered by the HEART score, emergency department physicians still deviated from the recommendations for treatment 18% of the time — usually for patients at low risk. 

In fact, 41% of the low-risk patients were kept for “prolonged observation” — 36% of them received additional testing and the rest were admitted, with a median stay of 2-3 days. Of those admitted (67 patients), 42 of them were diagnosed with nonspecific or atypical chest pain, 18 with non-cardiac chest pain, and 7 were determined to have cardiac ischemia. In most of the cases, the emergency physician declined to provide reasons for not adhering to the protocol.2

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Using the HEART score to guide therapy resulted in reduced direct healthcare costs — an average of 200 € less than usual care with slightly better outcomes. Unfortunately, it made little improvement on resource utilization, since a large proportion of patients with low HEART scores were kept for observation or even admitted for additional testing. 

According to the authors, one possible explanation for the latter finding is that it is often difficult to change physician behaviors. This phenomenon is well understood by guideline committees, who struggle to disseminate new recommendations down to physicians who are already set in their ways.

Another reason why physicians may be reluctant to adhere to the treatment algorithm is that there is a significant risk of missing a true myocardial infarction (MI), and this risk may promote “risk-adverse” practices. In our increasingly litigious society, this is not a surprise. The estimated overall cost to our healthcare system of practicing defensive medicine is around $46 billion annually.3 

Tort reform has been proposed to help physicians feel more comfortable practicing without the constant threat of being sued. While that might be a viable solution, it may not completely solve the issue. Some studies have estimated that the actual number of defensive orders may be much lower than previously estimated. 

For example, in one study, the authors found that while internists from Massachusetts estimated that 27% of CT scans were done for purely defensive reasons, the actual number of radiological studies ordered out of fear of litigation was closer to 2%.4 

The problem with such studies is that it is very difficult to truly assess what is done for defensive reasons. It is not difficult to fathom a scenario where clinicians are reflexively defensive, and so their orders become reflexive as well. In some cases, doctors may have convinced themselves that self-protective orders are truly best for their patients, and therefore they may not view those behaviors as a defensive strategy. For such reasons, I question the validity of any study that claims to be able to assess the incidence or prevalence of defensive medicine. 

Hence, while tort reform may be one possible way of promoting adherence to use of the HEART score, a more testable and more practical intervention — given current politics— might be to provide emergency physicians with feedback about those low-risk patients who were discharged within 4 hours of their emergency-department visit. If emergency physicians were frequently reassured that these patients do well despite not being admitted, over time they may feel more confident about discharging low-risk patients. 

Another strategy might be to build clear referral pathways to ensure that patients being discharged have immediate primary-care and cardiology follow-up, as well as access to further risk stratification with stress testing. Case managers could arrange follow-up appointments and even outpatient stress tests from the emergency department. 

While this strategy seemingly requires some additional resource utilization in the emergency department, it could prove to be very cost effective, given that the average length of stay for a low-risk patient is 2-3 days — at a cost that often far exceeds the cost of a 5-star hotel. 

To sum up, the HEART score has again been shown to be a safe risk-stratification tool for chest pain, but it does not seem to do much for reducing hospital utilization and admissions. However, with the right implementation environment, it has the potential for substantially reducing healthcare utilization and costs — and for improving patient outcomes. 


  1. Six AJ, Backus BE and Kelder JC. “Chest Pain in the Emergency Room: Value of the HEART Score.” Netherlands Heart Journal. 2008;16: 191-196.
  2. Poldervaart JM, et al. “Effect of Using the HEART Score in Patients with Chest Pain in the Emergency Department.” Ann Intern Med. 2017;166: 689-697.
  3. Mello MM, et al. “National Costs of the Medical Liability System.” Health Aff. 2010;29: 1569-1577.
  4. Rothberg M, Class J and Bishop T. “The Cost of Defensive Medicine on 3 Hospital Medicine Services.” JAMA Internal Medicine. 2014;174: 1867-1868.