What is the GRACE Score?

The Global Registry of Acute Coronary Events (GRACE) score was developed from a multinational registry of over 11,000 patients and is now the preferred ACS risk stratification tool in ESC guidelines. Unlike the TIMI score, GRACE uses continuous variables and provides a personalised mortality probability rather than a categorical risk group.

Key Variables

The GRACE score incorporates eight variables:

• •Age — the single most powerful predictor
• •Heart rate — tachycardia reflects haemodynamic compromise
• •Systolic blood pressure — hypotension carries the highest weight
• •Serum creatinine — renal dysfunction independently predicts mortality
• •Killip class — clinical heart failure classification
• •Cardiac arrest at admission — strongest binary predictor (+39 points)
• •ST deviation on ECG — reflects ischaemia burden
• •Elevated cardiac enzymes — confirms myonecrosis

Interpreting the Score

Clinical Pearls

Cardiac arrest at admission adds 39 points — always document resuscitated cardiac arrest in your ACS assessment. This single variable can shift a patient from intermediate to high risk. GRACE 2.0 (available at gracescore.org) now predicts 1-year and 3-year mortality without requiring creatinine clearance calculation, making it more accessible at the bedside. Combining GRACE with TIMI: Many centres use TIMI for rapid triage and GRACE for formal risk documentation. GRACE is better calibrated for in-hospital mortality; TIMI is faster to calculate mentally.

ESC 2023 Recommendations

The 2023 ESC NSTE-ACS guidelines use GRACE as the primary risk stratification tool:

• •GRACE > 140 = very high risk → immediate invasive strategy within 2 hours
• •GRACE 109–140 = high risk → early invasive strategy within 24 hours
• •GRACE < 109 = low risk → consider non-invasive testing before discharge

Practical Application

When a patient presents with chest pain and troponin elevation, calculate GRACE immediately using the online calculator or your institution's EMR. The score should drive your conversation with cardiology about catheterisation timing — not just the troponin level alone.

Remember: GRACE is a continuous score. A patient with GRACE 138 is nearly as high-risk as one with GRACE 145. Avoid treating the threshold as a hard cut-off.