GRACE Risk Score (In-Hospital)

Global Registry of Acute Coronary Events (GRACE) in-hospital risk score for acute coronary syndromes, estimating in-hospital mortality from age, heart rate, systolic blood pressure, creatinine, Killip class, cardiac arrest, ST-segment deviation, and cardiac enzymes.

Cardiology CardiologyEvidence-BasedUpdated 2026-08-15

Age*

Heart rate on admission*

Systolic blood pressure on admission*

Serum creatinine on admission*

Killip class*

Cardiac arrest at admission*

ST-segment deviation on admission ECG*

Elevated cardiac enzymes on admission*

Clinical Notes

Formula

Sum of points from the GRACE in-hospital nomogram (age, heart rate, systolic blood pressure, creatinine, Killip class, cardiac arrest at admission, ST-segment deviation, elevated cardiac enzymes). Total range approximately 2–372; higher scores indicate higher in-hospital mortality.

Normal Range

2–372 points

Clinical Notes

GRACE in-hospital score predicts in-hospital mortality in ACS: ≤108 points (low risk, <1%), 109–140 (intermediate risk, 1–3%), >140 (high risk, >3%). The GRACE model is the only widely validated ACS risk score using continuous variables; the discrete nomogram is the point-based version used at the bedside.

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.

Calculator Information

Specialty

Cardiology

📋 Reference Ranges

Normal Range

2–372 points

What This Calculator Measures

Estimates in-hospital mortality risk for patients with acute coronary syndromes (STEMI, NSTEMI, or unstable angina) using the validated GRACE model.

How to Use

Enter the patient's age, admission heart rate, systolic blood pressure, and serum creatinine.
Select the Killip class and note whether cardiac arrest occurred at admission.
Indicate ST-segment deviation and elevated cardiac enzymes on admission.
Sum the points and interpret against the in-hospital mortality risk categories.

Interpretation Guide

Total score ≤108: low risk (<1% in-hospital mortality); 109–140: intermediate risk (1–3%); >140: high risk (>3%). The GRACE model is the preferred risk stratification tool recommended by European and US guidelines for ACS.

Age-specific interpretation

Clinical Significance

GRACE is the most extensively validated ACS risk model, using continuous physiological variables to estimate in-hospital mortality more accurately than point-score-only tools.

When to Use

Risk stratification of all ACS presentations (STEMI, NSTEMI, UA)
Guiding decisions on early invasive vs. conservative management
Estimating in-hospital mortality for prognosis and consent

When Not to Use

Non-ACS chest pain syndromes
As a substitute for continuous clinical monitoring and repeat biomarkers

Limitations

The discrete nomogram approximates the continuous GRACE model; values between points require interpolation.
The original risk model is time-limited (in-hospital); separate GRACE models exist for 6-month and discharge risk.
Assumes standardized ACS care; outcomes vary with local systems and treatment.

Worked Example

A 78-year-old woman presents with STEMI, heart rate 100 bpm, blood pressure 110/70 mmHg, creatinine 1.4 mg/dL, Killip class II, ST-segment elevation, and positive troponin. No cardiac arrest.

Inputs:

age: 75

heart-rate: 15

sbp: 43

creatinine: 10

killip: 20

cardiac-arrest: 0

st-deviation: 28

elevated-enzymes: 14

GRACE in-hospital score 205 — HIGH risk (>3% predicted in-hospital mortality). Urgent risk-directed therapy, including early invasive strategy.

Evidence

Source: GRACE Registry
Reference: Granger CB, et al. Predictors of hospital mortality in the global registry of acute coronary events. Arch Intern Med. 2003;163(19):2345-2353.
Reviewed By: MedCalcHub Clinical Team
Version: 1.0
Updated: 2026-08

Granger CB, et al. Arch Intern Med. 2003;163(19):2345-2353.

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. (Level I)

Frequently Asked Questions

What does a GRACE score mean?

108 or less: low risk (less than 1% in-hospital mortality). 109-140: intermediate risk (1-3%). More than 140: high risk (more than 3%). GRACE is the preferred ACS risk tool per European and US guidelines.

When should I use GRACE vs TIMI?

GRACE is more comprehensive and is the guideline-recommended tool for ACS risk stratification. TIMI is simpler but considers fewer variables. GRACE is generally preferred for both in-hospital and 6-month prognosis.

Does GRACE apply to all ACS types?

Yes. GRACE is validated for STEMI, NSTEMI, and unstable angina. It estimates in-hospital mortality. Separate GRACE models exist for 6-month and discharge risk.

Disclaimer: This calculator is intended for educational and clinical decision support purposes only. It does not replace clinical judgment in the acute management of ACS.