Enhancing HEART Score Risk Stratification With Delta Troponin and Limit-of-Quantitation–Based Criteria: A Retrospective Cohort Analysis

The HEART score is a validated tool for chest pain risk stratification¹. Although high-sensitivity troponin (hs-cTn) improves diagnostic accuracy², the score does not incorporate troponin dynamics (delta) or Limit of Quantification (LOQ) thresholds. Delta troponin helps distinguish acute myocardial injury (AMI) from chronic elevation³, and LOQ-based subtraction for serial low values may further refine risk. This study assessed whether adding delta troponin and LOQ subtraction to the HEART score improves AMI detection and risk stratification.

We performed a retrospective cohort study of 1,598 adults presenting to the ED at UF Health Shands Hospital (June 2019–July 2023) with chest pain and serial hs-cTn testing. Patients with STEMI, missing HEART scores, or absent serial troponins were excluded. Data included demographics, HEART components, troponin values, and outcomes (30-day readmission, MACE). Two modifications were tested: (1) adding delta troponin for intermediate/high-risk patients, and (2) LOQ subtraction (

Delta troponin identified 16.1% (23/143) of AMI cases among patients initially flagged by HEART score, with a 17.4% (4/23) MACE rate. Additionally, 0.48% (7/1,455) of patients below initial hs-cTn cutoffs were reclassified as AMI, with 14.3% (1/7) experiencing MACE. Using GatorHEART, 46% (397/866) of patients with ≥2 troponins below LOQ were reclassified: 41% (353/397) from intermediate to low risk and 5% (44/397) from high to intermediate risk. No patients reclassified as low risk had MACE, compared with 2.27% (1/44) in the intermediate-risk group.

Adding delta troponin and LOQ-based subtraction to the HEART score improves AMI detection and safely downgrades selected patients without missed MACE. These changes may reduce unnecessary admissions and improve ED resource use; however, prospective validation is needed to confirm clinical benefits.