Role of GRACE Scoring in Managing Patients with Acute Coronary Syndrome
The GRACE (Global Registry of Acute Coronary Events) score is the recommended primary risk stratification tool for patients with acute coronary syndrome (ACS) due to its superior predictive ability for both short-term and long-term mortality compared to other risk scores and subjective physician assessment. 1, 2
Components and Calculation of GRACE Score
The GRACE score uses 8 clinical variables to calculate risk:
- Age
- Killip class
- Systolic blood pressure
- Heart rate
- ST-segment deviation
- Cardiac arrest on admission
- Serum creatinine
- Cardiac biomarker elevation 1, 2
Risk Stratification Categories
The GRACE score categorizes patients into three risk groups:
| Risk Category | GRACE Score | In-hospital Mortality |
|---|---|---|
| Low | ≤108 | <1% |
| Intermediate | 109-140 | 1-3% |
| High | >140 | >3% |
Clinical Applications of GRACE Score
1. Guiding Invasive Management Decisions
- Patients with high GRACE scores (>140) derive significant benefit from early invasive management 2
- The GRACE score helps identify patients who would benefit from risk-determined care interventions 1
2. Prognostication
GRACE 2.0 calculator provides mortality estimates at:
- Hospital discharge
- 6 months
- 1 year
- 3 years
- Combined risk of death or MI at 1 year 2
The GRACE score has maintained its excellent discriminative ability despite advances in ACS management over time 3
3. Comparison with Other Risk Scores
- GRACE score has demonstrated superior predictive ability for mortality compared to the TIMI risk score 2, 4
- The GRACE risk score has a C-statistic of 0.83-0.91 for predicting in-hospital mortality, showing excellent discrimination 4, 5
- GRACE score remains valid across all ACS subtypes (STEMI, NSTEMI, and unstable angina) 6, 7
Important Considerations
Not a Diagnostic Tool: The GRACE score should not be used as a diagnostic tool but rather to stratify risk in patients with suspected or confirmed ACS 1, 2
Long-term Prediction: The GRACE score maintains its predictive value for mortality up to 4-5 years after the initial ACS event 6, 7
Implementation: The GRACE score can be calculated using web applications or mobile devices, available at www.outcomes-umassmed.org/grace 1, 2
Evidence Gap: Despite its excellent predictive ability, there is insufficient evidence that routine use of risk scores in hospitalized patients with STEMI/NSTE-ACS translates into reduced risk of cardiovascular events 1
Recalibration: While the discriminative ability of the GRACE score remains excellent across different healthcare settings, the predicted probability of in-hospital mortality may require recalibration in specific healthcare settings as treatments advance 5
Clinical Algorithm for Using GRACE Score
- Calculate GRACE score for all patients with confirmed or suspected ACS
- Stratify patients into low, intermediate, or high-risk categories
- For high-risk patients (GRACE >140):
- Consider early invasive strategy
- More intensive monitoring and treatment
- For intermediate-risk patients (GRACE 109-140):
- Consider early invasive strategy based on other clinical factors
- Close monitoring
- For low-risk patients (GRACE ≤108):
- Consider non-invasive testing or early discharge strategies
- Less intensive monitoring may be appropriate
The GRACE score remains a powerful and validated tool for risk stratification in ACS management, with consistent performance across different healthcare settings and time periods.