From the Guidelines
The GRACE score and GRACE 2.0 are distinct risk assessment tools for predicting outcomes in acute coronary syndromes, with GRACE 2.0 offering improved statistical methods, flexibility, and accessibility compared to the original GRACE score. The original GRACE score was developed to predict in-hospital mortality using variables such as age, heart rate, and systolic blood pressure, as outlined in the 2007 ACC/AHA guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction 1. In contrast, GRACE 2.0 maintains these variables but uses improved statistical methods to predict both in-hospital and long-term mortality, as discussed in the context of risk assessment tools for acute coronary syndromes 1.
Some key differences between the two scores include:
- The ability of GRACE 2.0 to predict long-term mortality, in addition to in-hospital mortality
- The flexibility of GRACE 2.0 in allowing risk calculation even when some variables are missing
- The improved accessibility of GRACE 2.0 through online calculators and smartphone applications
- The better calibration of GRACE 2.0 across different patient populations and geographic regions
The GRACE risk model, as mentioned in the 2012 ACCF/AHA focused update, is a useful tool for predicting in-hospital mortality and can guide treatment type and intensity 1. However, GRACE 2.0 is the preferred choice for risk assessment in acute coronary syndromes due to its enhanced predictive accuracy and practical utility. The improved statistical modeling in GRACE 2.0 provides better calibration across different patient populations and geographic regions, making it a more reliable tool for clinicians to make evidence-based decisions regarding the intensity of care and interventions needed for patients with acute coronary syndromes.
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) 2.
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 2.
- The GRACE 2.0 score has been validated externally in several studies, 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 2, 4.
- The GRACE 2.0 score has been shown to perform well in predicting 1-year mortality after hospital discharge in patients with ACS, including those with ST-elevation MI (STEMI) and non-ST-elevation MI (NSTEMI) 4.
Performance of GRACE Score and GRACE 2.0 Score in Different Populations
- The GRACE score has been validated in various populations, including Canadian and Japanese patients with ACS 5, 3.
- The GRACE 2.0 score has been shown to perform well in a contemporary multiracial cohort of patients with ACS, including black patients with ACS 4.
- The GRACE score and GRACE 2.0 score have been shown to have high diagnostic accuracy for predicting in-hospital and 360-day mortality in Japanese patients with STEMI 5.
Modifications to the GRACE Risk Score
- A modified GRACE score that incorporates high-sensitivity cardiac troponin (hs-cTn) T at presentation has been shown to improve mortality risk prediction in patients with ACS 6.
- The modified GRACE score has been shown to have superior performance compared to the original GRACE score in terms of reclassification and discrimination for in-hospital, 30-day, and 1-year mortality endpoints 6.