GRACE score: in-hospital mortality nomogram for acute coronary syndromes (Granger 2003)

The GRACE score adds points for eight findings at admission with an acute coronary syndrome (ACS): age, heart rate, systolic blood pressure, creatinine, Killip class, cardiac arrest, ST-segment deviation and elevated cardiac enzymes. The total runs up to 372, and Granger's 2003 nomogram reads it off as an in-hospital mortality percentage. Magent's calculator adds the nomogram points from the values you supply and returns the total and that printed readout.

Not a medical device. Not a diagnosis or dosing recommendation.

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Acute coronary syndrome calculators
Granger CB et al. · 2003
The GRACE score table
Worked examples
Frequently asked questions

What is the GRACE score?

GRACE stands for the Global Registry of Acute Coronary Events, a large international registry of people admitted with ACS. Granger and colleagues used it to find which admission findings predicted death in hospital and turned them into a points nomogram.

Several GRACE models exist. This calculator uses the original 2003 in-hospital nomogram. It isn't the later continuous GRACE 2.0 model, and it isn't the 6-month or post-discharge model. Totals and percentages from those models don't match this one.

The GRACE score table

Age          <30: 0   30-39: 8   40-49: 25   50-59: 41   60-69: 58
             70-79: 75   80-89: 91   90 or more: 100
Heart rate   <50: 0   50-69: 3   70-89: 9   90-109: 15   110-149: 24
             150-199: 38   200 or more: 46
Systolic BP  <80: 58   80-99: 53   100-119: 43   120-139: 34
             140-159: 24   160-199: 10   200 or more: 0
Creatinine   0-0.39: 1   0.4-0.79: 4   0.8-1.19: 7   1.2-1.59: 10
(mg/dL)      1.6-1.99: 13   2.0-3.99: 21   4 or more: 28
Killip       I: 0   II: 20   III: 39   IV: 59
Cardiac arrest at presentation        39
ST-segment deviation                  28
Elevated initial cardiac enzymes      14

Printed readout (total -> in-hospital mortality %)
  60 or less 0.2 | 70 0.3 | 80 0.4 | 90 0.6 | 100 0.8 | 110 1.1
  120 1.6 | 130 2.1 | 140 2.9 | 150 3.9 | 160 5.4 | 170 7.3
  180 9.8 | 190 13.0 | 200 18.0 | 210 23.0 | 220 29.0 | 230 36.0
  240 44.0 | 250 or more 52.0

Exact expression the calculator uses:

GRACE = age_points(<30:0, 30-39:8, 40-49:25, 50-59:41, 60-69:58, 70-79:75, 80-89:91, >=90:100) + heart_rate_points(<50:0, 50-69:3, 70-89:9, 90-109:15, 110-149:24, 150-199:38, >=200:46) + sbp_points(<80:58, 80-99:53, 100-119:43, 120-139:34, 140-159:24, 160-199:10, >=200:0) + creatinine_mg_dl_points(0-0.39:1, 0.4-0.79:4, 0.8-1.19:7, 1.2-1.59:10, 1.6-1.99:13, 2.0-3.99:21, >=4:28) + killip(1:0, 2:20, 3:39, 4:59) + 39 if cardiac_arrest + 28 if st_deviation + 14 if elevated_enzymes; Granger 2003 in-hospital GRACE 1.0 nomogram; max 372; in_hospital_mortality_percent is that paper's printed score readout (score<=60 → 0.2; then the labeled 70-240 percents at or below the total; score>=250 → 52); not ESC 108/140 cutoffs, not GRACE 2.0, not Fox 2006 6-month

Inputs

Input	Meaning	Unit	Range
`age`	Age	years	18 to 120
`heart_rate_bpm`	Heart rate at admission	beats/min	20 to 300
`sbp_mm_hg`	Systolic blood pressure	mm Hg	40 to 300
`creatinine_mg_dl` or `creatinine_umol_l`	Initial serum creatinine	mg/dL or µmol/L	0.1 to 20 mg/dL
`killip_class`	Killip class I to IV	class	1 to 4
`cardiac_arrest`	Cardiac arrest at presentation	yes/no
`st_deviation`	ST-segment deviation on the first ECG	yes/no
`elevated_enzymes`	Raised initial cardiac enzymes	yes/no

Killip class, arrest, ST deviation and enzymes are answers you supply. The calculator doesn't read an ECG or a lab report.

How the calculation works

Look up each band. Age, heart rate, systolic pressure and creatinine each fall in one band with its points. Systolic pressure runs the other way: lower pressure scores more.
Add Killip and the three flags. Killip class adds 0 to 59. Arrest adds 39, ST deviation 28 and raised enzymes 14.
Total. The sum is at most 372.
Read off. The calculator takes the highest labelled tick at or below the total and returns its printed percentage. A total of 60 or less reads 0.2; 250 or more reads 52.0.

The readout steps between labelled ticks. It doesn't draw a smooth curve between them.

Units

Creatinine can go in as mg/dL or µmol/L. A µmol/L value is divided by 88.42 first. In Magent's reference cases, 88.42 µmol/L becomes 1.0 mg/dL. If both units are sent, the mg/dL value is used.

Worked examples

These use Magent's own expected values for the calculator. Examples 2 to 6 change one thing from Example 1.

Example 1: a typical admission, Killip class I

Age 65 gives 58. Heart rate 80 gives 9. Systolic 130 gives 34. Creatinine 1.0 gives 7.
Killip I, no arrest, no ST deviation, normal enzymes add 0.
Total 108. Readout 0.8% (the 100 tick).

Example 2: the same patient in Killip class III

Killip III adds 39.
Total 147. Readout 2.9% (the 140 tick).

Example 3: the same patient with ST-segment deviation

ST deviation adds 28.
Total 136. Readout 2.1% (the 130 tick).

Example 4: the same patient with elevated enzymes

Raised enzymes add 14.
Total 122. Readout 1.6% (the 120 tick).

Example 5: systolic pressure 200 mm Hg

Systolic 200 or more gives 0 instead of 34.
Total 74. Readout 0.3% (the 70 tick).

Example 6: creatinine entered in µmol/L

Creatinine 88.42 µmol/L converts to 1.0 mg/dL, which gives 7, as in Example 1.
Total 108. Readout 0.8%.

History of the GRACE score

Granger CB, Goldberg RJ, Dabbous O and the Global Registry of Acute Coronary Events Investigators published the nomogram in Archives of Internal Medicine in 2003, in "Predictors of hospital mortality in the global registry of acute coronary events". Later GRACE work produced 6-month and continuous models, which are separate from this one.

When it's used

The score is worked out at admission with an acute coronary syndrome, to put the in-hospital risk of death on a common scale.

Where it's used

Emergency departments, coronary care units and cardiology wards.

Who uses it

Cardiologists, emergency physicians and the teams caring for people with ACS. The calculator looks up the bands, adds the points and reads off the percentage.

Limits of the calculation

It uses the 2003 in-hospital nomogram. GRACE 2.0 and the 6-month model give different numbers.
The percentage is a registry readout for the total, not a forecast for one person.
It doesn't apply the later 108/140 risk groups and doesn't decide on timing of any procedure.
Killip class, arrest, ST deviation and enzymes are answers you supply; a wrong answer changes the total.
This page doesn't say what a result means for a particular person.

Clinical decisions belong to a qualified clinician who knows the patient.

TIMI UA/NSTEMI and TIMI STEMI use shorter lists of features from the TIMI trials.
HEART is for chest pain in the emergency department before ACS is established.
Killip classifies heart failure signs on its own; GRACE uses it as one input.

Glossary

ACS: acute coronary syndrome, which covers unstable angina and heart attack.
Killip class: a grading of heart failure signs from I (none) to IV (cardiogenic shock).
ST-segment deviation: a shift of part of the ECG trace that can signal heart muscle injury.
Nomogram: a chart that turns findings into points and points into a risk.

Common mistakes

Mixing GRACE models. A 2003 in-hospital total can't be read against GRACE 2.0 or 6-month figures.
Scoring low blood pressure as low risk. Systolic points rise as pressure falls.
Entering creatinine in the wrong unit. Use mg/dL or µmol/L, and the calculator converts µmol/L.
Interpolating the readout. The percentage steps at the labelled ticks.

Source

Granger CB, et al. Predictors of hospital mortality in the global registry of acute coronary events. Arch Intern Med. 2003;163(19):2345-2353. DOI: 10.1001/archinte.163.19.2345. PMID: 14581255

Frequently asked questions

What is the highest GRACE score?

372 in the 2003 in-hospital nomogram.

What does a GRACE score of 108 mean here?

In Example 1, 108 reads off as 0.8% in-hospital mortality from the printed nomogram.

Is this the same as GRACE 2.0?

No. This is the 2003 in-hospital integer nomogram. GRACE 2.0 is a later continuous model with different outputs.

Does the calculator use the 108 and 140 cut-offs?

No. Those risk groups came from later guidance and aren't printed in Granger 2003.

What does GRACE stand for?

Global Registry of Acute Coronary Events.