Class I (+0)
No clinical signs of heart failure
Class II (+20)
Rales, S3 gallop, or elevated JVP
Class III (+39)
Acute pulmonary edema
Class IV (+59)
Cardiogenic shock
Cardiac Arrest at Admission (+39)
ST-Segment Deviation (+28)
Elevated Cardiac Enzymes (+14)
GRACE (Global Registry of Acute Coronary Events) ACS Risk Score
The GRACE ACS Risk Score is a comprehensive tool used to predict the risk of in-hospital and 6-month mortality for patients presenting with an acute coronary syndrome (ACS), including STEMI, NSTEMI, and unstable angina.
Scoring Predictors
The score is calculated based on eight independent predictors:
- Age: Points increase with age.
- Heart Rate: Higher rates receive more points.
- Systolic Blood Pressure: Lower pressures receive more points.
- Serum Creatinine: Higher levels receive more points.
- Killip Class: Assesses the severity of heart failure (Class I-IV).
- Cardiac Arrest at Admission: A significant high-risk feature.
- ST-Segment Deviation: Indicates significant myocardial ischemia.
- Elevated Cardiac Enzymes: Confirms myocardial necrosis.
Risk Stratification
The total score stratifies patients into three risk tiers:
| Risk Tier | Score | In-Hospital Mortality | 6-Month Mortality |
|---|---|---|---|
| Low | ≤ 108 | <1% | <3% |
| Intermediate | 109-140 | 1-3% | 3-8% |
| High | > 140 | >3% | >8% |
Clinical Usefulness
The GRACE score is a powerful tool for guiding management strategies:
- Low-Risk Patients: May be suitable for a more conservative approach and earlier discharge.
- Intermediate to High-Risk Patients: Are more likely to benefit from an early invasive strategy, such as angiography and revascularization, and more potent antithrombotic therapies.
It provides a more nuanced risk assessment than many other scores by incorporating a wider range of clinical variables, including renal function and hemodynamic status.
References
- Granger, C. B., Goldberg, R. J., Dabbous, O., Pieper, K. S., Eagle, K. A., Cannon, C. P., ... & Fox, K. A. (2003). Predictors of hospital mortality in the global registry of acute coronary events. Archives of internal medicine, 163(19), 2345-2353.
- Eagle, K. A., Lim, M. J., Dabbous, O. H., Pieper, K. S., Goldberg, R. J., Van de Werf, F., ... & Granger, C. B. (2004). A validated prediction model for all forms of acute coronary syndrome: estimating the risk of 6-month postdischarge death in an international registry. JAMA, 291(22), 2727-2733.
- Fox, K. A., Dabbous, O. H., Goldberg, R. J., Pieper, K. S., Eagle, K. A., Van de Werf, F., ... & Granger, C. B. (2006). Prediction of risk of death and myocardial infarction in the six months after presentation with acute coronary syndrome: prospective multinational observational study (GRACE). BMJ, 333(7578), 1091.
- Amsterdam, E. A., Wenger, N. K., Brindis, R. G., Casey, D. E., Ganiats, T. G., Holmes, D. R., ... & Zieman, S. J. (2014). 2014 AHA/ACC guideline for the management of patients with non–ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 64(24), e139-e228.
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