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

Clinical decision-support tool for qualified healthcare professionals. Results are not a diagnosis and should not replace professional clinical judgment.

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

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.

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.

How the Calculation Works

The GRACE in-hospital score sums pre-scored points from eight admission variables: age, heart rate, systolic blood pressure, serum creatinine, Killip class, cardiac arrest at admission, ST-segment deviation, and elevated cardiac enzymes. Higher totals indicate greater in-hospital mortality risk (low <= 108, intermediate 109-140, high > 140).

Variables Explained

Age

Age band, scored 0 (under 30 years) up to 100 (90 years or older).

Heart rate on admission

Heart rate band, scored 0 (under 50 bpm) up to 46 (200 bpm or higher).

Systolic blood pressure on admission

Systolic blood pressure band, scored 58 (under 80 mmHg) down to 0 (200 mmHg or higher).

Serum creatinine on admission

Creatinine band, scored 1 (0-0.39 mg/dL) up to 28 (4.0 mg/dL or higher).

Killip class

Killip class, scored 0 (class I) up to 59 (class IV cardiogenic shock).

Cardiac arrest at admission

Cardiac arrest at admission; Yes contributes 39 points.

ST-segment deviation on admission ECG

ST-segment deviation; Yes contributes 28 points.

Elevated cardiac enzymes on admission

Elevated cardiac enzymes; Yes contributes 14 points.

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 It Is Useful

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 It Is Not Useful

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

Common Mistakes

Using the in-hospital GRACE nomogram to estimate 6-month or discharge mortality, for which separate GRACE models exist.
Entering actual age, heart rate, systolic pressure, or creatinine values rather than the pre-scored nomogram points for each band.
Applying the GRACE score to non-ACS chest pain syndromes instead of confirmed STEMI, NSTEMI, or unstable angina presentations.

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

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

Evidence & References

Source:: GRACE Registry
Content 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.