I. How to Use

When to Use

Apply the GRACE score to patients with confirmed acute coronary syndromes to estimate mortality risk, guide timing of invasive strategies, and support prognostic discussions. It should not be used in patients with undifferentiated chest pain before ACS is diagnosed

Pearls / Pitfalls

Strengths:

  1. This is a widely validated, guideline-endorsed prognostic model.

  2. GRACE 2.0 improves accuracy with non-linear modeling and extended (1–3 year) mortality predictions.

  3. The tool uses readily available clinical, ECG, and lab variables.

  4. The score has strong discrimination across multiple populations (>20,000 patients in external validations).

  5. It helps guide timing of invasive strategies.

  6. The tool is very useful for structured communication of risk with patients/families.

Pitfalls:

  1. The tool is prognostic only and is not designed for diagnosing ACS or undifferentiated chest pain.

  2. Use of this tool should not delay time-sensitive reperfusion in STEMI.

  3. Calibration can drift over time or vary by setting; local validation/recalibration may be required.

  4. The tool may over- or underestimate risk in elderly/frail patients; does not include frailty or comorbidity burden.

  5. The score omits social determinants (e.g., socioeconomic deprivation) that might influence outcomes.

  6. The tool requires Killip class and creatinine. Missing or subjective inputs can affect accuracy.

Why to Use

The GRACE score can be used because it is extensively validated and a guideline-endorsed tool for risk stratification in acute coronary syndromes. By combining readily available clinical, ECG, and laboratory data, it provides a reliable estimate of short- and long-term mortality, helping clinicians identify high-risk patients who benefit most from early invasive strategies and intensified medical therapy. Beyond guiding management, the score supports meaningful prognostic discussions with patients and families, promotes standardized decision-making across providers, and aligns care with evidence-based recommendations. Its consistent performance across large, diverse international cohorts makes it a valuable tool for improving both clinical outcomes and communication in the care of ACS patients.

II. Next Steps

Advice

The GRACE Score is a prognostic tool to support decision-making. Use it alongside clinical judgment, ECG, troponin, and patient stability. Discuss results with patients and families to guide expectations and shared decisions.

Management

The ESC 2023 and ACC/AHA 2025 acute coronary syndrome guidelines support the use of the GRACE score to identify high-risk patients with acute coronary syndrome for risk stratification to early invasive strategy (GRACE Score >140). In patients with STEMI, GRACE score should not delay invasive strategy but can be used to provide prognostic information.

Critical Actions

Mortality estimate increases as the GRACE score increases.

This tool can be used as one factor in determining a course of care and may assist in communication with the patient about their risk. It should not be used in isolation when determining a treatment plan.

Ensure high-risk patients have guideline-directed care during their hospitalization, as well as appropriate specialist and primary care follow-up upon discharge.

III. Evidence

Evidence Appraisal

The GRACE 2.0 score is a well-validated, guideline-endorsed tool for risk stratification in acute coronary syndromes, with strong discrimination (Area Under the Curve [AUC] ≈0.8) and clear clinical utility in guiding invasive strategy timing and prognostic discussions. Derived from a large, multinational registry (N=21,688) and externally validated in diverse populations, it demonstrates broad applicability, though calibration may drift over time and across healthcare systems, requiring local validation and potential recalibration. Its strengths include clinical relevance, feasibility, and ease of use, but limitations include reliance on subjective inputs (e.g., Killip class), lack of frailty or socioeconomic factors, and risk over- or underestimation in elderly or deprived groups. Overall, GRACE 2.0 should be used as a robust prognostic aid to inform management and communication in ACS, but always alongside clinical judgment, local validation, and consideration of patient context.

Formula

Cumulative model, see: https://pubmed.ncbi.nlm.nih.gov/24561498/

Fox KA, Fitzgerald G, Puymirat E, et al. Should patients with acute coronary disease be stratified for management according to their risk? Derivation, external validation and outcomes using the updated GRACE risk score. BMJ Open. 2014;4(2):e004425.

Facts & Figures

Score Interpretation:

GRACE Score >140 suggests consideration for early invasive strategy.

Risk estimates of mortality can be found in the original derivation and validation study: https://pubmed.ncbi.nlm.nih.gov/24561498/

Fox KA, Fitzgerald G, Puymirat E, et al. Should patients with acute coronary disease be stratified for management according to their risk? Derivation, external validation and outcomes using the updated GRACE risk score. BMJ Open. 2014;4(2):e004425.

Literature

Original/Primary

https://pubmed.ncbi.nlm.nih.gov/17032691/
Fox KA, Dabbous OH, Goldberg RJ, Pieper KS, Eagle KA, Van de Werf F, Avezum A,Goodman SG, Flather MD, Anderson FA Jr, Granger CB. Prediction of risk of death and myocardial infarction in the six months after presentation with acute coronary syndrome: prospective multinational observational study (GRACE). BMJ. 2006 Nov 25;333(7578):1091. Epub 2006 Oct 10. PubMed PMID: 17032691; PubMed Central PMCID: PMC1661748.

https://pubmed.ncbi.nlm.nih.gov/24561498/
Fox KA, Fitzgerald G, Puymirat E, et al. Should patients with acute coronary disease be stratified for management according to their risk? Derivation, external validation and outcomes using the updated GRACE risk score. BMJ Open. 2014;4(2):e004425.

Validation

https://pubmed.ncbi.nlm.nih.gov/19699862/
Elbarouni B, Goodman SG, et al. Validation of the Global Registry of Acute Coronary Event (GRACE) risk score for in-hospital mortality in patients with acute coronary syndrome in Canada. Am Heart J. 2009 Sep;158(3):392-9. doi: 10.1016/j.ahj.2009.06.010.

https://pubmed.ncbi.nlm.nih.gov/27561191/
Huang W, FitzGerald G, Goldberg RJ, et al. Am J Cardiol. 2016 Oct 15;118(8):1105-1110. doi: 10.1016/j.amjcard.2016.07.029. Epub 2016 Jul 29.

https://pubmed.ncbi.nlm.nih.gov/35354660/
Van der Sangen NM, Azzahhafi J, Yin DR et al. Open Heart. 2022 Mar;9(1):e001984. doi: 10.1136/openhrt-2022-001984.

Other References (including meta-analyses, CPGs, and impact analyses)

Anderson F, FitzGerald G. Methods and formulas used to calculate the GRACE Risk Scores for patients presenting to hospital with an acute coronary syndrome: Center for Outcomes Research, University of Massachusetts Medical School.

Jobs A, Mehta SR, Montalescot G, et al. Lancet. 2017 Aug 19;390(10096):737-746. doi: 10.1016/S0140-6736(17)31490-3. Epub 2017 Aug 1.

Byrne RB, Rossello X, Coughlan JJ, et al. Eur Heart J Acute Cardiovasc Care. 2024 Feb 9;13(1):55-161. doi: 10.1093/ehjacc/zuad107.

Rao SV, O’Donoghue ML, Ruel M, et al.Circulation. 2025 Apr;151(13):e771-e862. doi: 10.1161/CIR.0000000000001309. Epub 2025 Feb 27.