Cardiology

Global Registry of Acute Coronary Events Score

8 inputsCardiology

Predict in-hospital and 6-month mortality in acute coronary syndrome (ACS).

Calculate

GRACE Score calculator

Result

105points

Low risk — 6-month mortality < 3%

How to use it

1
Record admission vitals. First HR and SBP on presentation.
2
Obtain admission bloods. Creatinine; note if troponin/CK-MB elevated.
3
Assess ECG & Killip. New ST deviation scores 28 points; Killip ≥II adds 20.

When to use it

Apply to all patients presenting with NSTE-ACS (NSTEMI or unstable angina) to guide timing of coronary angiography and determine in-hospital and post-discharge prognosis.

NSTEMI/UA risk stratification: High GRACE (>140) benefits from early invasive strategy within 24 hours.
STEMI post-PCI: Predicts 6-month mortality; guides rehabilitation intensity.
Not a sole triage tool: Use with troponin trajectory and clinical context.

About the score

The GRACE (Global Registry of Acute Coronary Events) score is the recommended risk stratification tool for patients with non-ST-elevation acute coronary syndrome (NSTE-ACS), including NSTEMI and unstable angina. It was derived from a multinational registry of over 100,000 ACS patients and predicts both in-hospital and 6-month mortality using eight clinical variables. The score informs the timing of coronary angiography: very high-risk patients require an immediate invasive strategy (<2 hours), while an early invasive strategy within 24 hours should be considered for high-risk patients. The ESC 2023 ACS guidelines say GRACE risk models should be considered for estimating prognosis (Class IIa, Level B) and list a GRACE score >140 among the high-risk criteria.

Scoring criteria

Age (years)Continuous variable — older age scores higher: Variable
Killip class (I–IV)I=no HF, II=mild HF, III=pulmonary oedema, IV=cardiogenic shock: Variable
Systolic blood pressure (mmHg)Lower BP scores higher: Variable
ST-segment deviation on ECG: Variable
Cardiac arrest at admission: Variable
Serum creatinine (µmol/L): Variable
Positive cardiac biomarkers (troponin): Variable
Heart rate (bpm)Higher HR scores higher: Variable

Score interpretation

< 109Low riskIn-hospital mortality <1%; selective invasive strategy
109–140Intermediate riskIn-hospital mortality 1–3%; invasive strategy during the admission if other high-risk criteria are present
> 140High riskIn-hospital mortality >3%; consider an early invasive strategy (<24h)

Guideline recommendation

ESC 2023 ACS Guidelines: an early invasive strategy within 24 hours should be considered in patients with at least one high-risk criterion: confirmed NSTEMI, dynamic ST-segment or T-wave changes, transient ST-segment elevation, or a GRACE score >140 (Class IIa, Level A). Very high-risk criteria (haemodynamic instability or cardiogenic shock, recurrent or refractory chest pain, life-threatening arrhythmia or cardiac arrest, mechanical complications, acute heart failure from ongoing ischaemia, recurrent dynamic ECG changes) call for an immediate invasive strategy regardless of the GRACE score (Class I, Level C).

ESC 2023Acute Coronary Syndromes 2023

Clinical pearls

Use the online GRACE 2.0 calculator for exact score computation — manual estimation is error-prone due to the continuous variable scoring.
The GRACE score guides the timing of the invasive strategy (immediate, within 24 hours, or during the admission), not whether to perform angiography at all.
Any single very-high-risk criterion (haemodynamic instability, cardiogenic shock) mandates immediate (<2h) angiography, whatever the GRACE score.
Re-calculate GRACE after any significant change in haemodynamic status or biomarker results during the initial assessment period.

Limitations

Requires clinical input not always available at first contact (exact creatinine, troponin status).
Less applicable in patients with baseline renal impairment or known cardiomyopathy where initial values are abnormal.
The TIMI score for NSTEMI offers simpler calculation at the expense of predictive accuracy.

A reference for clinicians and students, not medical advice. A score supports a decision; it does not make one. Check every result against the patient in front of you and your local protocol.

At a glance

Specialty: Cardiology
Inputs: 8
Type: Formula
Guidelines from: ESC, AHA, ACC

Frequently asked questions

What is a high GRACE score?

A GRACE score >140 indicates high in-hospital mortality risk (>3%) and is one of the high-risk criteria for which the ESC 2023 guidelines advise considering an early invasive strategy within 24 hours. Haemodynamic instability or any other very-high-risk feature calls for immediate angiography, whatever the score.

What is the difference between GRACE and TIMI score in ACS?

The GRACE score is more accurate and guideline-preferred for NSTE-ACS because it was derived from a larger real-world registry and incorporates continuous variables (age, BP, HR, creatinine). The TIMI score is simpler to calculate at the bedside but has lower discriminatory accuracy. The ESC 2023 guidelines say GRACE risk models should be considered for estimating prognosis (Class IIa, Level B).