Loading your page…
Loading your page…
Predict in-hospital and 6-month mortality in acute coronary syndrome (ACS). GRACE score guides invasive strategy timing in NSTEMI and unstable angina per ESC guidelines.
The GRACE (Global Registry of Acute Coronary Events) score is the recommended risk stratification tool for patients with non-ST-elevation acute coronary syndrome (NSTE-ACS), including NSTEMI and unstable angina. It was derived from a multinational registry of over 100,000 ACS patients and predicts both in-hospital and 6-month mortality using eight clinical variables. The score directly informs the timing of coronary angiography: very high-risk patients require immediate invasive strategy (<2 hours), while high-risk patients should undergo early invasive strategy within 24 hours. ESC 2023 ACS guidelines designate GRACE as the preferred quantitative risk tool for NSTE-ACS.
Apply to all patients presenting with NSTE-ACS (NSTEMI or unstable angina) to guide timing of coronary angiography and determine in-hospital and post-discharge prognosis.
GRACE Score — Variables & Points
Age (years)
Continuous variable — older age scores higher
Killip class (I–IV)
I=no HF, II=mild HF, III=pulmonary oedema, IV=cardiogenic shock
Systolic blood pressure (mmHg)
Lower BP scores higher
ST-segment deviation on ECG
Cardiac arrest at admission
Serum creatinine (µmol/L)
Positive cardiac biomarkers (troponin)
Heart rate (bpm)
Higher HR scores higher
Low risk
In-hospital mortality <1%; selective invasive strategy
Intermediate risk
In-hospital mortality 1–3%; early invasive (<24–72h)
High risk
In-hospital mortality >3%; early invasive strategy (<24h)
ESC 2023 ACS Guidelines (Class I, Level A): GRACE score ≥140 indicates high risk requiring early invasive strategy within 24 hours. Very high-risk criteria (haemodynamic instability, refractory chest pain, life-threatening arrhythmia) require immediate angiography regardless of GRACE score.
Use the online GRACE 2.0 calculator for exact score computation — manual estimation is error-prone due to the continuous variable scoring.
GRACE score guides invasive strategy TIMING (immediate vs 24h vs 72h), not whether to perform angiography at all.
A GRACE score >140 combined with any single very-high-risk criterion (haemodynamic instability, cardiogenic shock) mandates immediate (<2h) angiography.
Re-calculate GRACE after any significant change in haemodynamic status or biomarker results during the initial assessment period.
Requires clinical input not always available at first contact (exact creatinine, troponin status).
Less applicable in patients with baseline renal impairment or known cardiomyopathy where initial values are abnormal.
The TIMI score for NSTEMI offers simpler calculation at the expense of predictive accuracy.
Create a free Prognia account to use the GRACE Score calculator — including auto-scored results, interpretation, and CPD logging.
Free plan · No credit card · Instant access
A GRACE score >140 indicates high in-hospital mortality risk (>3%) and requires an early invasive strategy within 24 hours per ESC 2023 guidelines. Scores >200 in the context of haemodynamic instability constitute a very-high-risk presentation.
The GRACE score is more accurate and guideline-preferred for NSTE-ACS because it was derived from a larger real-world registry and incorporates continuous variables (age, BP, HR, creatinine). The TIMI score is simpler to calculate at the bedside but has lower discriminatory accuracy. ESC 2023 recommends GRACE for routine clinical use.