GRACE ACS Risk Score
GRACE risk score (in-hospital death nomogram, Granger 2003): estimates in-hospital mortality across the spectrum of acute coronary syndromes from 8 admission variables.
How to use & interpret
The GRACE score estimates mortality (in-hospital and at 6 months) in acute coronary syndrome and is the preferred tool for risk-stratifying NSTE-ACS in UK/ESC practice. It combines age, heart rate, systolic BP, creatinine, Killip class, cardiac arrest at admission, ST-segment deviation and raised cardiac markers.
Its main use is timing of an invasive strategy: higher-risk patients (commonly a GRACE >140) are offered early angiography (within ~24 hours), while lower-risk patients can follow a more selective pathway. It is more discriminating than TIMI, but should always be combined with the overall clinical picture.
Score interpretation
GRACE ≤ 108: in-hospital mortality < 1% (ESC NSTE-ACS risk groups).
→ Suitable for early discharge strategy. Consider non-invasive risk stratification.
GRACE 109–140: in-hospital mortality 1–3%.
→ Inpatient management. Coronary angiography within 72 hours.
GRACE > 140: in-hospital mortality > 3%. High-risk ACS.
→ Urgent coronary angiography (within 24 hours). Senior review. Intensive monitoring.
Interpretation bands for the GRACE. Apply clinical judgement and local guidance.
Frequently asked questions
What GRACE score means high risk?
A GRACE score above 140 is commonly used as the threshold for an early invasive strategy in NSTE-ACS, but local protocols and the full clinical context govern the actual decision.
References
- Granger CB, et al. Predictors of hospital mortality in the global registry of acute coronary events. Arch Intern Med. 2003;163(19):2345–2353.
- Hamm CW, et al. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2011;32(23):2999–3054.
Related
Curated clinical cross-links plus same-class fallbacks.
- Isosorbide Mononitrate (Stable Angina) · Nitrate / Stable Angina
- Nicorandil · Stable Angina
- Ranolazine · Refractory Stable Angina
- Glyceryl Trinitrate (Sublingual / IV) · Nitrate / Acute Angina
- Palivizumab · RSV Prophylaxis — Monthly Monoclonal Antibody (High-Risk Infants)
- Ziprasidone · Atypical Antipsychotic — D2/5-HT2A Antagonist (Low Metabolic Risk)
Featured in these MRCEM clinical pathways
The GRACE is covered in detail — with RCEM/NICE evidence base, indications and pitfalls — in the following exam-focused pathways on our sister siteReviseMRCEM.
MRCEM Primary / Intermediate / OSCE candidates: each pathway includes exam-style questions, RCEM/NICE citations, and FAQ summaries.
Decision support only — verify against a current formulary, NICE, or your local guideline before clinical use.