GRACE Score Calculator

Global Registry of Acute Coronary Events (GRACE) score for predicting in-hospital and 6-month mortality in acute coronary syndrome. Recommended by NICE and ESC guidelines for risk stratification in NSTEMI.

Important Clinical Disclaimer: The GRACE Score Calculator is intended for use by qualified healthcare professionals only. It is for educational and informational purposes and should not replace clinical judgement. Always interpret results alongside the full clinical picture and follow your local guidelines and protocols.
GRACE Score Parameters
Range: 18-120 years
Range: 20-250 bpm
Range: 40-300 mmHg
UK standard units (divide mg/dL by 0.0113)
About GRACE Score

The GRACE Score was developed from the Global Registry of Acute Coronary Events, comprising over 100,000 patients from 247 hospitals across 30 countries.

Key features:

  • Validated for STEMI, NSTEMI, and unstable angina
  • Predicts both in-hospital and 6-month mortality
  • Recommended by NICE (NG185) and ESC guidelines
  • More accurate than TIMI for mortality prediction
NICE recommends GRACE Score as the preferred tool for risk stratification in NSTEMI to guide timing of coronary angiography.
GRACE Risk Categories
Score Risk In-Hospital 6-Month
1-108 Low <1% <3%
109-140 Intermediate 1-3% 3-8%
>140 High >3% >8%
Killip Classification Guide
Class I No clinical signs of heart failure
Class II Rales/crackles in lower lung fields, S3, raised JVP
Class III Acute pulmonary oedema (rales >50% lung fields)
Class IV Cardiogenic shock (SBP <90, signs of hypoperfusion)

GRACE Score and NICE Guidelines (NG185)

NICE guideline NG185 (Acute Coronary Syndromes, 2020) recommends using GRACE Score to guide timing of coronary angiography in NSTEMI:

Immediate (<2 hours)

Criteria (any of):

  • Haemodynamic instability/cardiogenic shock
  • Recurrent/refractory chest pain despite medical therapy
  • Life-threatening arrhythmias
  • Mechanical complications of MI
  • Acute heart failure clearly related to NSTEMI
  • Recurrent dynamic ST-T changes
Early (<24 hours)

GRACE Score >140

Or any of:

  • Rise or fall in troponin
  • Dynamic ST or T-wave changes
Within 72 hours

GRACE Score <140

Without high-risk features:

  • No recurrent symptoms
  • No haemodynamic instability
  • No significant arrhythmias
  • Stable cardiac markers

GRACE Score Components

Variable Range Points Range Clinical Significance
Age Various ranges 0-100 Strongest predictor; older age significantly increases mortality risk
Heart Rate <50 to >200 bpm 0-46 Both bradycardia and tachycardia indicate higher risk
Systolic BP <80 to ≥200 mmHg 0-58 Hypotension strongly associated with poor outcomes
Creatinine Various ranges 1-28 Renal dysfunction indicates cardiorenal syndrome and worse prognosis
Killip Class I-IV 0-59 Heart failure signs strongly predict mortality
Cardiac Arrest Yes/No 0 or 39 Cardiac arrest at presentation indicates very high risk
ST Deviation Yes/No 0 or 28 ST changes indicate active ischaemia
Cardiac Markers Yes/No 0 or 14 Troponin elevation confirms myocardial injury

Frequently Asked Questions

For NSTEMI and unstable angina, GRACE is preferred by NICE and ESC guidelines as it has better discriminatory power for mortality prediction. Key differences:

  • GRACE: Uses 8 variables including continuous measures (age, HR, BP, creatinine) and renal function. More accurate but requires more data.
  • TIMI: Uses 7 binary variables. Simpler but less discriminatory. Good for rapid bedside assessment.

For STEMI, the TIMI STEMI score is purpose-designed for that population, though GRACE can also be used.

If creatinine is unavailable, you can:

  • Use the most recent known creatinine if available from recent records
  • Estimate based on patient's known renal status (normal ~80-100 µmol/L for healthy adults)
  • Calculate a preliminary score and update when results available
  • Use TIMI score as an interim assessment tool

For very high-risk features (cardiac arrest, cardiogenic shock, refractory ischaemia), proceed with urgent management regardless of calculated score.

Yes, GRACE was validated across the full spectrum of ACS including STEMI. However:

  • For STEMI, the priority is immediate reperfusion (primary PCI or thrombolysis)
  • Risk stratification should not delay treatment
  • GRACE can be calculated after initial stabilisation to guide ongoing management
  • The TIMI STEMI score was specifically designed for this population

GRACE has been extensively validated with good discrimination:

  • C-statistic 0.81-0.84 for in-hospital mortality
  • C-statistic 0.79-0.82 for 6-month mortality
  • Validated in multiple international cohorts
  • Performs better than TIMI and PURSUIT scores in head-to-head comparisons

However, all risk scores provide population-level estimates. Individual patient outcomes depend on many factors not captured in the score, and clinical judgement remains essential.

No. A low GRACE score indicates lower mortality risk, not the absence of significant coronary disease. Consider:

  • Many low-risk patients still benefit from angiography within 72 hours
  • Quality of life and symptom burden matter beyond mortality
  • Young patients may have significant disease despite low scores
  • Recurrent symptoms, positive stress testing, or patient preference may favour early invasive approach

GRACE helps prioritise and determine timing, not whether to investigate at all.

Disclaimer

This calculator is provided for educational and informational purposes only. It is not intended to be a substitute for professional medical advice, diagnosis, or treatment.

  • Always seek the advice of a qualified healthcare provider with any questions regarding a medical condition.
  • Never disregard professional medical advice or delay seeking it because of information from this tool.
  • Clinical decision-making should always incorporate the full clinical context, patient preferences, and local protocols.
  • The creators of this tool accept no liability for decisions made based on its output.

If you are a patient: please discuss any results with your healthcare provider. This tool is designed for use by medical professionals and may not be appropriate for self-assessment.

References

  1. Fox KA, et al. 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;333(7578):1091. doi:10.1136/bmj.38985.646481.55
  2. Granger CB, et al. Predictors of hospital mortality in the global registry of acute coronary events. Arch Intern Med. 2003;163(19):2345-2353. doi:10.1001/archinte.163.19.2345
  3. NICE. Acute coronary syndromes (NG185). 2020. https://www.nice.org.uk/guidance/ng185
  4. Collet JP, et al. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2021;42(14):1289-1367.
  5. GRACE Investigators. Rationale and design of the GRACE (Global Registry of Acute Coronary Events) Project: a multinational registry of patients hospitalized with acute coronary syndromes. Am Heart J. 2001;141(2):190-199.