HEART vs. GRACE scores for 30-day cardiovascular outcomes in acute chest pain : A systematic review and meta-analysis.

Abstract

Background: Acute chest pain is a common emergency department (ED) presentation requiring rapid risk stratification for major adverse cardiovascular events (MACE; including death, myocardial infarction, and urgent revascularization). While the HEART (History, ECG, Age, Risk factors, Troponin) and GRACE scores are widely used, their comparative predictive accuracy for short-term MACE remains unclear. This study aimed to directly compare the diagnostic performance of HEART and GRACE (Global Registry of Acute Coronary Events) in predicting 30-day MACE among ED patients with acute chest pain.

Methods: We systematically searched PubMed, Embase, Cochrane Library, Scopus, and Web of Science from inception to May 2025 for prospective cohort studies directly comparing HEART and GRACE scores. Included studies applied both scores at ED presentation, reported 30-day MACE (death, myocardial infarction, urgent revascularization), and provided data for 2 × 2 contingency tables. Pooled sensitivity, specificity, likelihood ratios (PLR/NLR), diagnostic odds ratio, and area under the curve (AUC) were calculated using a bivariate random-effects model. Heterogeneity was assessed via I² statistics, and subgroup analyses explored sources of variation.

Results: In total, 19 studies (14,862 patients) were included. The HEART score demonstrated significantly higher sensitivity (0.96, 95% CI: 0.94-0.98 vs. 0.88, 95% CI: 0.85-0.91; ratio: 1.09 [1.05-1.14]) and lower negative likelihood ratio (NLR: 0.08, 95% CI: 0.03-0.17 vs. 0.42, 95% CI: 0.39-0.46) than the GRACE score. Specificity was lower for HEART (0.50, 95% CI: 0.41-0.60) versus GRACE (0.61, 95% CI: 0.58-0.64), while GRACE showed higher specificity. HEART also had superior discriminative power (AUC: 0.80, 95% CI: 0.77-0.84 vs. 0.72, 95% CI: 0.69-0.75; ratio: 1.11 [1.07-1.15]). Subgroup analyses confirmed HEART's advantage in sensitivity across geographic regions and age groups, particularly in Eastern populations (sensitivity ratio: 1.57 [1.27-1.93]).

Conclusion: The HEART score outperforms GRACE in sensitivity and rule-out capability (lower NLR) for 30-day MACE in ED patients with acute chest pain, supporting its utility for safe discharge of low-risk individuals. GRACE's higher specificity may aid in identifying high-risk cases requiring intervention. Standardization of troponin assays and MACE definitions is critical for future implementation.