In-hospital mortality risk in acute coronary syndrome

What it is and when to use it

The GRACE Score (Global Registry of Acute Coronary Events) estimates in-hospital and 6-month mortality risk in patients with acute coronary syndrome (ACS), covering both ST-elevation and non-ST-elevation presentations. It combines eight variables: age, heart rate, systolic blood pressure, serum creatinine, Killip class, cardiac arrest at admission, ST-segment deviation, and elevated cardiac necrosis biomarkers. The ESC ACS guideline (2023) recommends it for risk stratification and to guide the timing of an invasive strategy in non-ST-elevation ACS.

How to interpret it

The score maps to risk categories. For in-hospital mortality, a GRACE ≤108 indicates low risk (<1%), 109-140 intermediate risk (1-3%) and >140 high risk (>3%). For 6-month mortality, ≤88 is low risk (<3%), 89-118 intermediate (3-8%) and >118 high (>8%). In non-ST-elevation ACS, a GRACE >140 identifies high-risk patients in whom an early invasive strategy (within 24 hours) is recommended.

Limitations and when not to use it

It was derived and validated in a large international cohort of patients with confirmed ACS; it is not validated for undifferentiated chest pain or to rule out ACS in the emergency department. It is a prognostic mortality tool, not a diagnostic one: it does not confirm or exclude infarction, does not assess bleeding risk (a dedicated score such as CRUSADE is needed for that), and does not by itself dictate revascularization. The GRACE 2.0 version extends estimates to 1-3 years and can substitute variables such as creatinine or Killip class with equivalents when these are unavailable.

Frequently asked questions

What is the difference between the GRACE Score and the TIMI Score?

Both stratify risk in ACS, but GRACE has stronger discriminative power for mortality and uses continuous variables (age, heart rate, blood pressure, creatinine), whereas TIMI is simpler and based on dichotomous points.

Does a high GRACE Score mean urgent catheterization is needed?

A GRACE >140 in non-ST-elevation ACS favors an early invasive strategy within 24 hours, but the final decision is integrated with the clinical picture, hemodynamic stability and other risk factors.

Is the GRACE Score useful for patients with ST-elevation myocardial infarction (STEMI)?

Yes, GRACE estimates mortality in both ST-elevation and non-ST-elevation ACS; in STEMI it adds prognostic information even though immediate reperfusion is already indicated by definition.