How to Calculate the GRACE Score for Acute Coronary Syndrome Patients
To calculate the GRACE score for your patient, you need to collect eight specific clinical variables and input them into the GRACE risk calculator, which is available online at www.outcomes-umassmed.org/grace.
Required Variables for GRACE Score Calculation
The GRACE risk score requires the following eight clinical variables 1, 2:
- Age (odds ratio 1.7 per 10 years)
- Heart rate (odds ratio 1.3 per 30-beat per minute increase)
- Systolic blood pressure (odds ratio 1.4 per 20 mmHg decrease)
- Serum creatinine level (odds ratio 1.2 per 1-mg per dL increase)
- Killip class (odds ratio 2.0 per class)
- Cardiac arrest during presentation (odds ratio 4.3)
- ST-segment deviation on ECG (odds ratio 2.4)
- Elevated cardiac biomarkers (odds ratio 1.6)
Step-by-Step Calculation Process
- Gather all required clinical data from your patient's presentation and initial workup
- Access the GRACE calculator at www.outcomes-umassmed.org/grace
- Input the eight variables into the online calculator or mobile application
- Obtain the GRACE risk score and corresponding mortality risk estimate
Interpreting the GRACE Score
The GRACE score categorizes patients into three risk groups 1, 2:
| Risk Category | GRACE Score | In-hospital Mortality |
|---|---|---|
| Low | ≤108 | <1% |
| Intermediate | 109-140 | 1-3% |
| High | >140 | >3% |
Clinical Application and Significance
The GRACE score has several important clinical applications:
- Excellent discrimination across all ACS subtypes (STEMI, NSTEMI, and unstable angina) with C-statistics of 0.83-0.91 for predicting in-hospital mortality 2, 3
- Long-term prognostic value maintained up to 4-5 years after the initial ACS event 2, 4
- Superior performance compared to other risk scores like TIMI for predicting long-term mortality 2
- Guides treatment decisions - patients with high GRACE scores (>140) derive significant benefit from early invasive management 2
Common Pitfalls and Considerations
- Missing data handling: If Killip class or serum creatinine values are unavailable, a modified score can be calculated by adding renal failure and use of diuretics, respectively 1
- Type 2 MI performance: The GRACE score has moderate discrimination (AUC 0.73) in type 2 MI compared to excellent discrimination (AUC 0.83-0.85) in type 1 MI 5
- Regional variations: Some studies suggest recalibration may be needed in specific healthcare settings despite excellent discrimination being maintained 3
- Not a diagnostic tool: The GRACE score should only be used for risk stratification in patients with confirmed or highly suspected ACS, not as a diagnostic tool 2
GRACE 2.0 Risk Calculator
The newer GRACE 2.0 calculator provides more comprehensive risk estimates 1, 2, 6:
- Mortality at hospital discharge
- Mortality at 6 months
- Mortality at 1 year
- Mortality at 3 years
- Combined risk of death or MI at 1 year
The GRACE 2.0 simplified algorithm has demonstrated excellent discrimination in contemporary multiracial cohorts (c-index = 0.77-0.94) 6.