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Chest pain accounts for a significant percentage of emergency department (ED) presentations. The HEART score and pathway have demonstrated an ability to appropriately risk stratify and discharge from the ED a significant proportion of patients.This review evaluates vital components of the HEART score and pathway, while discussing important considerations for current and future use.Chest pain is a common ED presentation, and several conditions associated with chest pain result in patient morbidity and mortality. One major disease is acute coronary syndrome (ACS). Despite the fear associated with this disease, it accounts for a minority of patients with chest pain in the ED. Emergency physicians rarely miss myocardial infarction (MI) or ACS, with miss rates < 1%. Many have sought a score and pathway that allow physicians to safely and reliably risk stratify patients. The HEART score and pathway have revolutionized chest pain evaluation, as they can risk stratify a significant number of patients accurately into separate categories based on history, electrocardiogram (ECG), troponin, age, and risk factors while displaying high sensitivity for MACE. Several intricacies must be considered in the use of this score including risk factors, ECG, troponin, age, history, gestalt, follow up, borderline score, and shared decision making. The HEART pathway can supplement clinician decision making.Appropriate use of the HEART pathway reliably risk stratifies patients. Physicians must consider several key components when utilizing the HEART pathway, and future directions may incorporate other patient factors.