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GRACE Score (ACS)

Global Registry of Acute Coronary Events — in-hospital and 6-month mortality

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Why use it

Superior discrimination to TIMI for ACS mortality prediction. Recommended by ESC guidelines as the preferred ACS risk score. Guides invasive strategy timing and intensity of treatment.

About

The GRACE score estimates in-hospital and 6-month mortality in patients with acute coronary syndromes (NSTEMI, STEMI, UA). It uses 8 variables including age, heart rate, systolic BP, creatinine, Killip class, cardiac arrest at admission, ST-segment deviation, and elevated cardiac enzymes. It has the highest discriminatory power among ACS risk scores.

When to use

  • Risk stratification after ACS diagnosis (NSTEMI, STEMI, UA)
  • Guides timing of invasive strategy (immediate, early, delayed)
  • In-hospital and post-discharge mortality estimation

Formula

Simplified scoring based on 8 variables: Age, HR, SBP, Creatinine, Killip class, Cardiac arrest, ST deviation, Elevated enzymes Total range: ~1-263 (in-hospital mortality)

Pearls & pitfalls

  • GRACE has the best c-statistic (~0.83) among ACS risk models.
  • Can be used for both STEMI and NSTEMI — unlike TIMI which has separate scores.
  • The simplified GRACE (8 variables) is most commonly used; original had 9.
  • ESC 2023 NSTE-ACS guidelines recommend GRACE for risk assessment and timing of angiography.
  • Online GRACE 2.0 calculator provides more precise estimates than the point-based system.
  • Cardiac arrest at admission is a powerful predictor — scores +39 points.

Next steps

Low risk (< 109): Conservative or elective invasive strategy. Intermediate (109-140): Early invasive within 72h. High risk (> 140): Urgent invasive strategy within 24h. Very high risk (> 140 + refractory symptoms): Immediate invasive < 2h.

Evidence

Derived from the GRACE registry (>40,000 patients from 14 countries). Validated externally in multiple populations. ESC Class I recommendation for NSTE-ACS risk stratification.

References

  1. Fox KA et al. Prediction of risk of death and myocardial infarction in the six months after presentation with acute coronary syndrome: prospective multinational observational study (GRACE). BMJ. 2006;333(7578):1091. — link
  2. Granger CB et al. Predictors of hospital mortality in the GRACE registry. Arch Intern Med. 2003;163(19):2345-2353. — link