Background Acute coronary syndrome (ACS) can be a diagnostic challenge in the emergency department (ED). Recently, the HEART score was developed, a simple bedside scoring system that quantifies risk of ischaemic events in patients with undifferentiated chest pain presenting in the ED.

Objective In this prospective cohort study, we compared the diagnostic accuracy of HEART score and clinical gestalt (clinical judgement) for diagnosing ACS in an unselected population of patients with chest pain presenting to the ED.

Methods HEART score (0–10) and clinical gestalt (low risk, intermediate risk or high risk of ACS) were prospectively determined in the ED in 255 patients presenting with chest pain by the treating physician. The reference standard was the presence of ACS, which was defined as either acute myocardial infarction (AMI) or the occurrence of a major adverse cardiac event within 6 weeks after presentation in the ED.

Results 75 out of 255 patients (29%) had an ACS. A HEART score ≤3 had a lower negative likelihood ratio (0.15 (0.06–0.36)) for ACS than a low risk based on clinical gestalt (0.35 (0.19–0.64)), whereas a high HEART score ≥7 had a higher positive likelihood ratio (5.2 (3.2–8.5) vs 3.1 (2.2–4.4)). However, c-statistic of HEART score was not significantly different from clinical gestalt (0.81 (0.76–0.86) vs 0.79 (0.73–0.84), p=0.13).

Conclusions Our study demonstrates that HEART score and clinical gestalt have similar diagnostic accuracy for diagnosing ACS in an unselected population of patients with chest pain presenting in the ED.