Article Text

Download PDFPDF

Do all HEART Scores beat the same: evaluating the interoperator reliability of the HEART Score
  1. William G P Niven1,
  2. David Wilson1,
  3. Steve Goodacre2,
  4. Alexander Robertson1,
  5. Samira Jane Green1,
  6. Tim Harris3
  1. 1Accident and Emergency Department, Homerton University Hospital, London, UK
  2. 2Health Services Research, School of Health and Related Research, University of Sheffield, Sheffield, UK
  3. 3Department of Emergency Medicine, Royal London Hospital, Barts Health, London, UK
  1. Correspondence to Dr William G P Niven, Accident and Emergency Department, Homerton University Hospital, London E9 6SR, UK; william.niven{at}


Background Patients presenting with chest pain represent a significant proportion of attendances to the ED. The History, ECG, Age, Risk Factors and Troponin (HEART) Score is validated for the risk stratification of suspected ischaemic chest pain within the ED. The goal of this research was to establish the interoperator reliability of the HEART Score as performed in the ED by different grades of doctor and nurse.

Methodology Patients with suspected ischaemic chest pain presenting to the ED of an inner city, London Hospital, were recruited prospectively between January and May 2016. Patients that had been enrolled in the study were interviewed by clinicians from four different categories: senior doctor, junior doctor, senior nurse and junior nurse. Clinicians, blinded to other raters’ results, calculated the HEART Scores for each patient with the assistance of a pocket-sized HEART Score card. The intraclass correlation coefficient (ICC) was calculated as the primary measure of reliability. 120 patients were required to achieve a desired power of 80%.

Results 88 complete comparisons were obtained. There were no significant differences between the distributions of HEART Scores for each clinician group (p=0.95). The ICC for the overall HEART Score was 0.91 (95% CI 0.87 to 0.93). The ICC for troponin and age were ‘1’, for ‘history’ 0.41 (95% CI 0.30 to 0.52), ‘ECG’ 0.64 (95% CI 0.54 to0.73) and ‘risk factors’ 0.84 (95% CI 0.79 to 0.89).

Conclusion This study demonstrates very strong overall interoperator reliability between the four groups of clinicians studied. This suggests that the HEART Score is reproducible when used by different professional groups and grade of clinician.

  • chest - non trauma
  • emergency care systems, emergency departments
  • cardiac care, diagnosis
  • nursing, emergency departments
  • management, risk management

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

View Full Text

Statistics from


  • Contributors WGPN was the lead author of this paper and generated the initial idea and subsequent design and planning for the study. WN wrote the IRAS application for the research ethics committee and, once approved was the chief investigator for the study; recruited the majority of the patients to the study and was responsible for the write up. DW helped with the planning of the study and was responsible for calculating the statistics used in this article. In addition, DW helped with the editing of the final document. SG was the supervisor for the thesis that was submitted as a master dissertation to the University of Sheffield and provided expertise in terms of study design and planning of the study and then helped with the reporting of the study in both this article and the aforementioned dissertation. ACER designed and delivered the teaching video that is referenced in the article and was one of the investigators that helped to recruit patients to the study. SJG was responsible for recruiting patients and analysing the data set for the outcome of acute coronary syndrome. TH helped refine the patient protocol for the initial study after an initial rejection from the research ethics committee. He was involved in helping to clarify the outcomes of interest and later in the editing of the manuscript.

  • Funding This work was supported by the Royal College of Emergency Medicine: grant number G/2014/3. Receipt of a Royal College of Emergency Medicine Grant of £4000 to fund this research project and collaboration with one of the original developers of the HEART Score to develop a teaching video for doctors and nurses on how to use the tool.

  • Competing interests Dr Niven reports grants from Royal College of Emergency Medicine, during the conduct of the study; and I have collaborated with Dr Barbra Backus, one of the original developers of the HEART Score, in creating a teaching video for the HEART Score.

  • Patient consent Not required.

  • Ethics approval NRES Committee London - City and East.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement There are no additional unpublished data from this study.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.