Clinical Decision-Making
Risk Stratification in Chest Pain: HEART vs TIMI vs GRACE
Compare the three major risk scores for acute coronary syndromes. Learn when to use HEART, TIMI, and GRACE scores in clinical practice.
Choosing the Right ACS Risk Score
Multiple validated scores exist for chest pain risk stratification. Each has specific strengths and ideal use cases.
HEART Score
Best For: Emergency Department triage
| Component | 0 points | 1 point | 2 points |
|---|---|---|---|
| History | Slightly suspicious | Moderately suspicious | Highly suspicious |
| ECG | Normal | Non-specific changes | Significant ST deviation |
| Age | <45 | 45-64 | ≥65 |
| Risk factors | None | 1-2 | ≥3 or known CAD |
| Troponin | ≤normal | 1-3x normal | >3x normal |
Interpretation:
- 0-3: Low risk (0.9-1.7% MACE), consider discharge
- 4-6: Intermediate risk, observation/workup
- 7-10: High risk, admission and intervention
TIMI Risk Score
Best For: NSTEMI/UA patients
7 factors, 1 point each:
- Age ≥65
- ≥3 CAD risk factors
- Known CAD (≥50% stenosis)
- ASA use in past 7 days
- ≥2 angina episodes in 24h
- ST deviation ≥0.5mm
- Elevated cardiac markers
Interpretation: Higher score = greater benefit from early invasive strategy
GRACE Score
Best For: Prognosis after ACS
Most complex but most accurate for:
- In-hospital mortality
- 6-month post-discharge mortality
- Benefits from invasive strategy
Variables: Age, HR, SBP, creatinine, Killip class, cardiac arrest, ST deviation, elevated markers
When to Use Which?
| Scenario | Preferred Score |
|---|---|
| ED chest pain evaluation | HEART |
| Admitted NSTEMI patient | TIMI or GRACE |
| Post-MI risk assessment | GRACE |
| Research/quality metrics | GRACE |
Related calculators
- HEART Score Calculator - Cardiology
- TIMI Risk Score Calculator - Emergency