What is the calculated GRACE score for a 50-year-old patient with a heart rate of 80 bpm, hypotension (90/60 mmHg), normal serum creatinine (0.9 mg/dL), Killip class 1, no cardiac arrest, ST depression in anterior leads, and positive troponin I (0.35 ng/mL)?

GRACE Score Calculation for 50-Year-Old Patient with NSTEMI

The calculated GRACE score for this patient is 113, indicating a low-intermediate risk of in-hospital mortality (approximately 1.8%).

Calculation Breakdown

Let's calculate the GRACE score systematically using the provided clinical parameters:

1. Age (50 years): 41 points

   • Age 50-59 years = 41 points 1

2. Heart Rate (80/min): 3 points

   • Heart rate 70-89 beats/min = 3 points 1

3. Systolic Blood Pressure (90/60 mmHg): 53 points

   • SBP 80-99 mmHg = 53 points 1

4. Killip Class (Class 1): 0 points

   • Killip Class 1 = 0 points 1

5. Serum Creatinine (0.9 mg/dL): 1 point

   • Creatinine 0.8-1.19 mg/dL = 1 point 1

6. Cardiac Arrest at Admission: 0 points

   • No cardiac arrest = 0 points 1

7. ST-Segment Deviation: 2 points

   • ST depression in anterior leads = 2 points 1

8. Elevated Cardiac Enzymes: 14 points

   • Troponin I positive (0.35) = 14 points 1

Total GRACE Score: 41 + 3 + 53 + 0 + 1 + 0 + 2 + 14 = 113 points

Risk Interpretation

According to the GRACE risk model nomogram 1:

• A score of 113 corresponds to approximately 1.8% risk of in-hospital mortality
• This places the patient in a low-intermediate risk category

Clinical Implications

• The GRACE score is one of the most accurate risk assessment systems for acute myocardial infarction with excellent discrimination (C-statistic >0.80) 2, 3
• This patient's score indicates they should receive guideline-directed medical therapy for NSTEMI
• The relatively low GRACE score suggests a favorable short-term prognosis, but the presence of ST depression and positive troponin still indicates significant coronary disease requiring appropriate intervention

Important Considerations

• The GRACE score has been validated across different age groups, including contemporary populations 4, 5, 6
• Hypotension (90/60 mmHg) contributes significantly to this patient's score and requires close monitoring despite the overall intermediate risk assessment
• Recent studies show that the GRACE score may slightly overestimate mortality risk in contemporary practice due to improvements in ACS management 5, so the actual risk may be even lower than calculated

The GRACE score should be used alongside clinical judgment to guide management decisions, particularly regarding the timing and approach to coronary angiography in this NSTEMI patient with ST depression.