From the Guidelines
The GRACE scoring system is a risk assessment tool used to predict mortality in patients with acute coronary syndromes, evaluating eight key variables and providing a total score that helps clinicians make evidence-based decisions regarding treatment intensity and urgency. The GRACE score is calculated based on age, heart rate, systolic blood pressure, serum creatinine level, Killip class, cardiac arrest at admission, ST-segment deviation on ECG, and elevated cardiac biomarkers, with higher scores indicating greater risk of in-hospital and 6-month mortality 1. The total score ranges from 0 to over 300, with scores above 140 generally indicating high risk requiring more aggressive intervention, as supported by the 2015 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation 1.
Key Components of the GRACE Scoring System
- Age
- Heart rate
- Systolic blood pressure
- Serum creatinine level
- Killip class
- Cardiac arrest at admission
- ST-segment deviation on ECG
- Elevated cardiac biomarkers
Clinical Application of the GRACE Scoring System
The GRACE score is valuable because it incorporates both clinical presentation and laboratory findings to provide an objective assessment of patient risk, allowing for appropriate triage and management strategies in acute coronary syndrome cases 1. The score can be used to identify patients who might benefit from aggressive therapy, including early myocardial revascularization.
Interpretation of GRACE Scores
Higher GRACE scores indicate a greater risk of mortality, with scores above 140 generally indicating high risk requiring more aggressive intervention 1. The GRACE clinical application tool can be downloaded to a handheld PDA to be used at the bedside and is available at www.outcomes-umassmed.org/grace 1.
From the Research
Definition of the Grace Scoring System
The Global Registry of Acute Coronary Events (GRACE) scoring system is a risk assessment tool used to predict mortality and major adverse cardiac events in patients with acute coronary syndrome (ACS) 2, 3, 4, 5.
Components of the GRACE Scoring System
The GRACE 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
- Not receiving in-hospital percutaneous coronary intervention 5
Predictive Value of the GRACE Scoring System
The GRACE scoring system has been shown to accurately predict long-term mortality post-ACS, with a C-index of 0.81 at 6 months, 1 year, 2 years, 3 years, and 0.80 at 4 years 5. The modified GRACE scoring system, which includes B-type natriuretic peptide precursor (BNP), has been found to have a higher predictive value than the traditional GRACE scoring system, with an Area Under Curve (AUC) of 0.809 compared to 0.786 3.
Comparison with Other Risk Scores
The GRACE scoring system has been compared to other risk scores, such as the CRUSADE score, and has been found to have superior predictive value for in-hospital mortality, with an AUC of 0.91 compared to 0.83 4. However, the performance of the GRACE score for predicting major bleeding has been found to be poor, with an AUC of 0.71 4.
Clinical Application
The GRACE scoring system can be used to risk-stratify patients with ACS and guide treatment decisions, such as the use of invasive coronary angiography and percutaneous or surgical revascularization 6.