maratoolTIMI vs HEART score
A side-by-side comparison of TIMI Risk Score (NSTEMI / UA) and HEART Score.
The TIMI risk score for unstable angina/NSTEMI and the HEART score both stratify ED chest pain patients by risk of 30-day major adverse cardiac events (MACE). TIMI was derived from clinical trial cohorts in patients already diagnosed with ACS; HEART was specifically developed for undifferentiated ED chest pain. Multiple head-to-head studies show HEART discriminates better in the typical low-to-moderate-risk ED population.
When to use TIMI Risk Score (NSTEMI / UA)
Use TIMI in patients with confirmed or strongly suspected ACS (positive troponin, ischemic ECG changes, or known coronary disease). It guides invasive strategy timing (early invasive vs conservative) and informs in-hospital management.
When to use HEART Score
Use HEART as the primary risk score in the ED for undifferentiated chest pain. A HEART score of 0–3 has < 2% 30-day MACE risk and supports safe discharge with outpatient follow-up. Scores 4–6 are intermediate (observation + serial troponin); ≥ 7 is high risk (admit for invasive workup).
Side-by-side comparison
| TIMI Risk Score (NSTEMI / UA) | HEART | |
|---|---|---|
| Derived population | TIMI 11B / ESSENCE trial patients (known ACS) | Undifferentiated ED chest pain |
| Inputs | 7 binary risk factors | 5 weighted factors (0–2 each) |
| Score range | 0–7 | 0–10 |
| Includes ECG? | Yes (ST changes) | Yes (weighted 0–2) |
| Includes risk factors? | Yes (≥ 3 CAD risk factors) | Yes (weighted 0–2) |
| Includes troponin? | Yes (binary elevated) | Yes (weighted by magnitude) |
| Best discrimination | Patients with confirmed ACS | Undifferentiated ED chest pain |
| Discharge threshold | Not designed for discharge decisions | ≤ 3 = consider discharge (< 2% 30-day MACE) |
Bottom line
HEART is the better score for ED chest pain triage and discharge decisions. TIMI is more useful once ACS is confirmed and you are choosing an invasive strategy.
Frequently asked questions
Can I discharge a HEART = 3 patient without serial troponin?
Modern protocols (HEART Pathway) combine HEART ≤ 3 with one or two negative high-sensitivity troponin values to enable safe discharge within 2–3 hours. Discharging on a single troponin and HEART alone (without serial measurement) is less well validated.
Does TIMI work for STEMI?
There is a separate TIMI risk score for STEMI (different inputs, different outcome — 30-day mortality). The TIMI score referenced in this comparison is the UA/NSTEMI version.
Is HEART validated in women?
Yes — HEART performs comparably in men and women, an improvement over older scores that under-detected risk in women. The "age ≥ 65" and "risk factor" components carry through equally.
What about EDACS?
EDACS (Emergency Department Assessment of Chest pain Score) is another modern alternative validated alongside HEART. Some centers prefer it; head-to-head data suggest similar discrimination.