GRACE score (in-hospital mortality)
Risk of in-hospital death in acute coronary syndrome (Granger 2003 nomogram)
- ESC 2023 ACS guideline
Sources last checked: 2026-10-27
GRACE score (in-hospital mortality)
Risk of in-hospital death in acute coronary syndrome (Granger 2003 nomogram)
This is the original in-hospital model from the GRACE registry (1999–2001). The risk bands shown are the ESC 2011 categories for NSTE-ACS; for STEMI the same publication uses ≤ 125, 126–154 and ≥ 155. The later GRACE 2.0 calculator uses continuous functions and gives slightly different estimates.
Interpretation
| ≤ 108 — low risk | ESC 2011 NSTE-ACS guideline: in-hospital death < 1 % for GRACE ≤ 108 in NSTE-ACS. |
|---|---|
| 109–140 — intermediate risk | ESC 2011: in-hospital death 1–3 % in NSTE-ACS. |
| > 140 — high risk | ESC 2011: in-hospital death > 3 % in NSTE-ACS. The ESC 2020 and 2023 guidelines list GRACE > 140 among the high-risk criteria for NSTE-ACS. |
What is the GRACE score (in-hospital mortality)?
The GRACE score for in-hospital mortality was derived by Granger and colleagues (2003) from 11,389 patients with acute coronary syndromes across 14 countries in the Global Registry of Acute Coronary Events. Eight variables available at admission — age, heart rate, systolic blood pressure, creatinine, Killip class, cardiac arrest, ST deviation and elevated cardiac enzymes — are converted to points and summed; the published nomogram maps the total to a probability of in-hospital death.
When to use it
- Risk stratification at admission in NSTE-ACS and STEMI
- Structuring the ESC high-risk assessment in NSTE-ACS (GRACE > 140)
- Comparing the risk profile of ACS cohorts
When not to use it
- Chest pain without a working diagnosis of ACS — use a chest-pain score such as HEART
- Long-term (6-month or later) risk — that needs the separate post-discharge GRACE model
How it is calculated
Sum of points (Granger 2003): Age < 30: 0 · 30–39: 8 · 40–49: 25 · 50–59: 41 · 60–69: 58 · 70–79: 75 · 80–89: 91 · ≥ 90: 100 Heart rate < 50: 0 · 50–69: 3 · 70–89: 9 · 90–109: 15 · 110–149: 24 · 150–199: 38 · ≥ 200: 46 Systolic BP < 80: 58 · 80–99: 53 · 100–119: 43 · 120–139: 34 · 140–159: 24 · 160–199: 10 · ≥ 200: 0 Creatinine (mg/dL) < 0.40: 1 · 0.40–0.79: 4 · 0.80–1.19: 7 · 1.20–1.59: 10 · 1.60–1.99: 13 · 2.00–3.99: 21 · ≥ 4.0: 28 Killip I: 0 · II: 20 · III: 39 · IV: 59; cardiac arrest 39; ST deviation 28; elevated cardiac enzymes 14
Clinical pearls and limitations
- This is the original in-hospital model from the GRACE registry (1999–2001). The risk bands shown are the ESC 2011 categories for NSTE-ACS; for STEMI the same publication uses ≤ 125, 126–154 and ≥ 155. The later GRACE 2.0 calculator uses continuous functions and gives slightly different estimates.
- In the Granger nomogram a total of about 100 points corresponds to 0.8 % in-hospital mortality, 150 to about 4 %, 200 to about 18 % and 250 to about 52 %.
- Killip class and cardiac arrest carry many points; examine for rales and jugular venous pressure before scoring.
- Creatinine on admission is used — later rises are not captured.
- The online GRACE 2.0 calculator uses continuous variables and may give slightly different estimates from this points table.
Frequently asked questions
What GRACE score is high risk?
In NSTE-ACS the ESC 2011 categories are ≤ 108 low (< 1 % in-hospital death), 109–140 intermediate (1–3 %) and > 140 high (> 3 %). For STEMI the cut-offs are 125 and 155.
GRACE or TIMI?
The ESC guidelines prefer GRACE for risk stratification in NSTE-ACS because it discriminates better; TIMI is simpler and needs no laboratory values beyond markers.
Why is my result different from the online GRACE calculator?
The online GRACE 2.0 model uses continuous functions for age, heart rate, blood pressure and creatinine; this page uses the original 2003 integer points.
Evidence and guidelines
- Primary source: Granger CB, Goldberg RJ, Dabbous O et al. Predictors of hospital mortality in the Global Registry of Acute Coronary Events. Arch Intern Med 2003;163(19):2345-2353.
- Hamm CW, Bassand JP, Agewall S 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 — table of GRACE risk categories for in-hospital death.
- Byrne RA et al. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J 2023;44:3720-3826.
Have a follow-up question?
Medelix answers clinical questions from current guidelines and studies — every statement with its source.
Related calculators
- TIMI risk score (UA/NSTEMI)14-day risk of death, MI or urgent revascularisation in unstable angina / NSTEMI
- HEART Score6-week MACE risk in chest pain
- Shock indexHeart rate ÷ systolic blood pressure — bedside marker of hypovolaemic shock
- eGFR (CKD-EPI 2021)Estimated glomerular filtration rate, race-free equation
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