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    GRACE ACS Risk and Mortality Calculator

    Estimates admission-6 month mortality for patients with acute coronary syndrome.
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    When to Use
    Pearls/Pitfalls
    Why Use

    A patient has a known STEMI or NSTEMI and you want to determine their mortality risk knowing basic factors about them.

    The GRACE Score is a prospectively studied scoring system to risk stratifiy patients with diagnosed ACS to estimate their in-hospital and 6-month to 3-year mortality. Like the TIMI Score, it was not designed to assess which patients’ anginal symptoms are due to ACS.

    Note: The GRACE Score was recently improved (GRACE 2.0); MDCalc uses the GRACE 2.0 scoring system, but we will discuss the GRACE model below.

    • The GRACE Score involves 8 variables from history, exam, EKG and laboratory testing. (GRACE 2.0 allows for substitutions of Killip Class for diuretic usage and for serum creatinine with history of renal dysfunction).
    • This score has been validated in >20,000 patients in multiple databases and is extremely well studied and supported.
    • The NICE guidelines recommend the GRACE Score for risk stratification of patients with ACS.
    • Many guidelines recommend more aggressive medical management for patients with a high mortality (or even early invasive management for these patients). Knowing this patient’s risk early may help with management and prognostication/goals of care discussions with patient and family.
    • A patient with some nonspecific features of their workup (history, EKG, troponin) can be more objectively risk stratified for their chest pain, quantify their risk, and potentially lead to shorter hospital stays, fewer inappropriate interventions and more appropriate interventions.
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    Evidence
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    Critical Actions

    For information regarding risk levels based on Score, the GRACE Research Group offers more information here.

    Formula

    Addition of the selected points:

    Facts & Figures

    Score interpretation:

    Grace Score Range Mortality Risk
    0-87 0-2%
    88-128 3-10%
    129-149 10-20%
    150-173 20-30%
    174-182 40%
    183-190 50%
    191-199 60%
    200-207 70%
    208-218 80%
    219-284 90%
    ≥ 285 99%

    Evidence Appraisal

    The GRACE (Global Registry of Acute Coronary Events) is a massive, international database of ACS in 94 hospitals in 14 countries which gives it excellent external validity a priori.

    Patients were entered into the study if they had ACS:

    • Signs or symptoms of acute cardiac ischemia plus:
      • EKG findings consistent with ACS or
      • Cardiac biomarker serial increases consistent with ACS or
      • Documented coronary artery disease.
    • This ACS could not be secondary to trauma, surgery, or other significant co-morbidity.
    • In-hospital mortality status was available in 98.1% of the 11,389 ACS patients studied.
    • 22% of the in-hospital deaths occurred within 24 hours of admission, suggesting that this registry contains a very sick cohort of patients.

    Of note, the GRACE 2.0 evaluated variables for non-linear mortality associations (thus providing a more accurate estimate of outcome). GRACE 2.0 also includes mortality estimates up to 3 years after the ACS event via several other data sets with longer followup windows.

    Dr. Joel Gore

    From the Creator

    What's the difference between the GRACE and GRACE 2.0 scores?
    GRACE 2.0 is an improved and refined list of outcomes from GRACE; instead of using score ranges to calculate outcomes like in-hospital mortality, we can actually calculate a mortality for every score. People should use GRACE 2.0.
    Is there a difference between GRACE 2.0 and Mini-GRACE?
    No – they're completely substitutable. We just developed the Mini-GRACE in case a clinician did not know a patient's Killip class or did not have their creatinine available (normally these are available).
    What outcome are you using as a cardiologist? In-hospital? 1-year? 3-year?
    We use the in-hospital mortality outcome with the GRACE score. It helps us determine disposition in our STEMI patients; those with a score of 130 or higher go to the ICU after catheterization, and those with lower scores can go to our step down unit. We haven't had any bad outcomes and we've also saved a number of ICU beds this way for other patients that need ICU-level care.
    We'll also occasionally use the GRACE score on our high risk NSTEMI patients to consider doing early invasive management as opposed to delayed intervention in our NSTEMI patients.

    About the Creator

    Joel Gore, MD, is a cardiologist at the UMass Memorial Medical Center, where he is also the Director of the Anticoagulation Clinic. He is a professor of Cardiovascular medicine at the University of Massachusetts Medical School and specializes in cardiac prevention. Dr. Gore earned his medical degree from the University of Calgary, and completed residency and fellowship at UMass Memorial Center. He is also board certified in Addiction Psychiatry and Internal Medicine.

    To view Dr. Joel Gore's publications, visit PubMed

    Dr. Keith A. A. Fox

    From the Creator

    Why did you develop the GRACE ACS Risk Score? Was there a clinical experience that inspired you to create this tool for clinicians?
    We developed the GRACE ACS risk score because we saw the need for better risk stratification to guide treatment of ACS and to help address the “Treatment-Risk” paradox.
    What pearls, pitfalls and/or tips do you have for users of the GRACE ACS Risk Score? Are there cases in which it has been applied, interpreted, or used inappropriately?
    It is important to consider not only total risk, but also risk that can be modified (MI risk helps with this).
    What recommendations do you have for health care providers once they have applied the GRACE ACS Risk Score? Are there any adjustments or updates you would make to the score given recent changes in medicine?
    The GRACE 2.0 (which MDCalc uses) has been shown to be more accurate than the original score.
    Other comments? Any new research or papers on this topic in the pipeline?
    Yes! We are currently working on developing models to identify modifiable risk and long term risk in ACS patients.

    About the Creator

    Keith A. A. Fox, MBBS, FRCP, is professor of cardiology at the University of Edinburgh. He was a founding fellow/Board member of the European Society of Cardiology and awarded the Silver Medal of the ESC in 2010 for his contributions to cardiology. Professor Fox's major research interests are in the mechanisms and manifestations of acute coronary arterial disease and his work extends from underlying biological mechanisms to in vivo study and clinical trials.

    To view Dr. Keith A. A. Fox's publications, visit PubMed