What is the difference between the Global Registry of Acute Coronary Events (GRACE) score and the GRACE 2.0 score?

From the Guidelines

The GRACE score and GRACE 2.0 are both risk assessment tools used to predict outcomes in patients with acute coronary syndrome (ACS), but they differ in several important ways, with GRACE 2.0 providing more precise risk estimates and allowing for calculation of both in-hospital and longer-term mortality risk. The original GRACE score was developed in 2003 and uses eight variables: age, heart rate, systolic blood pressure, creatinine level, Killip class, cardiac arrest at admission, ST-segment deviation, and elevated cardiac enzymes 1. GRACE 2.0, introduced in 2014, is an updated version that maintains the same variables but incorporates revised statistical methods to improve prediction accuracy.

Key Differences

• The key difference is that GRACE 2.0 provides more precise risk estimates and allows for calculation of both in-hospital and longer-term (6-month, 1-year, and 3-year) mortality risk, whereas the original GRACE score was primarily designed for in-hospital and 6-month outcomes.
• Additionally, GRACE 2.0 is more accessible through online calculators and smartphone applications, making it easier to implement in clinical practice.
• Both scoring systems help clinicians stratify ACS patients according to risk and guide treatment decisions, but GRACE 2.0 offers enhanced predictive capability and greater flexibility in assessing risk over different time horizons.

Clinical Application

• The GRACE risk model, which predicts in-hospital mortality (and death or MI), can be useful to clinicians to guide treatment type and intensity 1.
• The GRACE score can be used to identify patients at high risk for clinical events, and an early invasive strategy may be recommended for these patients 1.
• The decision to implement an initial conservative (vs initial invasive) strategy in patients with ACS may be made by considering physician and patient preference, as well as the patient's risk profile according to the GRACE score 1.

Recommendations

• An early invasive strategy is recommended in patients with ACS who have refractory angina or hemodynamic or electrical instability, or who have an elevated risk for clinical events according to the GRACE score.
• The GRACE score can be used to guide treatment decisions and stratify patients according to risk, with GRACE 2.0 offering enhanced predictive capability and greater flexibility in assessing risk over different time horizons.

From the Research

Overview of GRACE Score and GRACE 2.0 Score

• The Global Registry of Acute Coronary Events (GRACE) score is a risk stratification tool used to predict mortality and other outcomes in patients with acute coronary syndromes (ACS) 2, 3.
• The GRACE 2.0 score is an updated version of the original GRACE score, which uses non-linear associations and is designed to be easier to use and more accurate in predicting short-term and long-term mortality and death/myocardial infarction (MI) 4, 5.

Key Differences Between GRACE Score and GRACE 2.0 Score

• The GRACE 2.0 score uses non-linear algorithms to improve model discrimination, whereas the original GRACE score uses linear associations 4.
• The GRACE 2.0 score has been validated externally in various cohorts, including the French registry of Acute ST-elevation and non-ST-elevation MI (FAST-MI) 2005 and the Transitions, Risks, and Actions in Coronary Events Center for Outcomes Research and Education (TRACE-CORE) cohort 4, 5.
• The GRACE 2.0 score has been shown to perform well in predicting 1-year mortality after hospital discharge in patients with ACS, with excellent model discrimination (c-index = 0.77) 5.

Performance of GRACE Score and GRACE 2.0 Score

• The original GRACE score has been validated in various populations, including Canadian and Japanese patients with ACS, and has been shown to have excellent discrimination for in-hospital mortality (c statistic = 0.84) 2, 3.
• The GRACE 2.0 score has been shown to have improved discrimination and calibration compared to the original GRACE score, with a c-index of 0.82 for 1-year mortality in the overall population 4.
• A modified GRACE score that incorporates high-sensitivity cardiac troponin (hs-cTn) T at presentation has been shown to have improved predictive value for mortality risk estimates compared to the original GRACE score 6.