From the Guidelines
The GRACE risk score is the most widely recommended tool to calculate ischemic risk after an acute coronary syndrome (ACS). The GRACE score incorporates key clinical variables including age, heart rate, systolic blood pressure, creatinine level, cardiac arrest at admission, ST-segment deviation, elevated cardiac enzymes, and Killip class to predict both in-hospital and 6-month mortality risk 1. For practical implementation, clinicians should calculate the GRACE score at presentation and again at discharge to guide treatment decisions.
Key Components of the GRACE Risk Score
- Age
- Heart rate
- Systolic blood pressure
- Creatinine level
- Cardiac arrest at admission
- ST-segment deviation
- Elevated cardiac enzymes
- Killip class
The GRACE score is particularly valuable because it helps determine which patients would benefit most from early invasive strategies versus conservative management, guides the intensity and duration of dual antiplatelet therapy, and identifies patients who require closer follow-up 1. The score's predictive accuracy stems from its development using a large, multinational registry of ACS patients, making it applicable across diverse healthcare settings.
Comparison with Other Risk Scores
The TIMI (Thrombolysis in Myocardial Infarction) risk score is an alternative that uses seven simple clinical variables but is generally considered less accurate than GRACE for long-term risk prediction 1. The PURSUIT risk model is another useful tool to guide the clinical decision-making process when the patient is admitted to the hospital, but it is not as widely recommended as the GRACE risk score.
Clinical Application
In clinical practice, the GRACE risk score can be used to stratify patients into different risk categories and guide treatment decisions accordingly. For example, patients with a high GRACE risk score may benefit from early invasive strategies, such as coronary angiography and percutaneous coronary intervention, while those with a low GRACE risk score may be managed conservatively. The GRACE risk score can also be used to identify patients who require closer follow-up and more intensive monitoring.
From the Research
Ischemic Risk Post Acute Coronary Syndrome (ACS)
The score used to calculate ischemic risk post ACS is the Global Registry of Acute Coronary Events (GRACE) risk score.
- The GRACE risk score is a well-validated tool for estimating short- and long-term risk in acute coronary syndrome (ACS) 2, 3, 4.
- The GRACE risk score 2.0 is a simplified algorithm that substitutes several variables that may be unavailable to clinicians and has been validated in contemporary multiracial ACS cohorts 3, 4.
- The GRACE risk score has been shown to accurately predict 6-month survival and long-term mortality post ACS 2.
- The score has also been used to predict the risk of stroke after an ACS, with a 6-month GRACE risk score being a useful tool to predict stroke after an ACS 5.
- Comparison of the GRACE and CRUSADE scores has shown that the GRACE score is superior in predicting in-hospital mortality, but both scores have poor performance for predicting major bleeding 6.
GRACE Risk Score
- The GRACE risk score is calculated based on several factors, including age, history of ischemic heart disease, heart failure, increased heart rate on admission, serum creatinine level, evidence of myonecrosis, and not receiving in-hospital percutaneous coronary intervention 2.
- The GRACE risk score 2.0 has been shown to have excellent model discrimination for predicting 1-year mortality after hospital discharge in ACS patients, with a c-index of 0.77 3.
- The score has been validated in various studies, including the GLOBAL LEADERS trial, which showed that the GRACE risk score 2.0 is valuable in discriminating high-risk ACS patients, but requires recalibration for better risk stratification 4.