Marburg Heart Score (MHS)

Why Use

Only ~1.5% of patients seen in primary care for chest pain have unstable coronary artery disease (CAD); the most common causes of chest pain in primary care are chest wall pain, gastrointestinal disease, and stable heart disease. Helps determine which outpatients with chest pain are at sufficiently low risk of unstable CAD to allow for further follow-up, testing and management to be done on a non-urgent outpatient basis (scores ≤2); and who may be at high enough risk of CAD to warrant further testing on an urgent or inpatient basis (scores ≥3).

When to Use

Patients ≥35 years old presenting with chest pain in a primary care setting. Should not be used in patients with a readily apparent cause of chest pain (e.g. trauma, infection), clear anginal equivalent symptoms (e.g. jaw pain, dyspnea on exertion, arm pain), or if other testing (e.g. electrocardiography, lab testing) has suggested a clearly cardiac etiology.

Formula

Pearls / Pitfalls

Not to be used for a positive diagnosis of angina or CAD, but as a negative tool to help assess who is low-enough risk to not need further evaluation. While scores ≤2 make unstable CAD highly unlikely (negative predictive value ~98%), scores ≥3 are only modestly predictive of CAD (positive predictive value ~23%). Validated in patients 35 years and older.

Management

For any primary care patient with chest pain, clinical stability can quickly be determined by evaluating the ABCs (airway, breathing, circulation). A patient who shows no signs of respiratory distress and has appropriate vital signs is unlikely to be acutely unstable and can be further evaluated in the office with appropriately targeted history, physical examination, and testing. If there is a readily apparent cause of chest pain other than CAD (e.g. trauma, infection), attention should be directed to these causes. If there are clearly anginal equivalent symptoms (e.g. jaw pain, dyspnea on exertion, arm pain), or if there are ischemic changes on EKG, then the MHS does not apply and urgent inpatient admission is warranted.

Critical Actions

No decision rule should trump clinical gestalt, and any patient with chest pain who is clinically unstable (respiratory distress or abnormal vital signs) warrants urgent or emergency inpatient admission.

Advice

When evaluating patients with chest pain in primary care, MHS ≤2 means the chest pain is highly unlikely to be due to unstable CAD (negative predictive value ~98%) and further outpatient evaluation is generally safe and appropriate. A primary care patient with a MHS ≤2 generally does not need urgent evaluation of chest pain (unless there is clear evidence of clinical instability) and further evaluation, including chest x-ray and stress testing, may be done through non-urgent outpatient follow-up. A primary care patient with a MHS ≥3 does not necessarily have unstable CAD, but since unstable CAD cannot be excluded, such patients generally warrant more urgent evaluation or inpatient admission.

More Information

Interpretation: Marburg Heart Score CAD risk Recommendation 0–2 3% Outpatient evaluation as needed ≥3 23% Consider urgent evaluation or inpatient admission