GRACE ACS Risk and Mortality Calculator
The GRACE score (Global Registry of Acute Coronary Events) is the guideline-recommended tool for risk-stratifying patients with acute coronary syndrome (ACS). Enter 8 clinical variables, age, heart rate, systolic blood pressure, serum creatinine, Killip class, and three binary findings, to get the GRACE score along with in-hospital and 6-month mortality risk categories for either NSTEMI/UA or STEMI. Results update instantly as you type.
What is the GRACE score?
The GRACE score (Global Registry of Acute Coronary Events) is a validated risk-stratification tool for patients presenting with acute coronary syndrome (ACS), which includes STEMI, NSTEMI, and unstable angina. It was developed from data on more than 11,000 patients across 94 hospitals in 14 countries, giving it robust real-world validity. The score combines eight clinical variables available at the time of hospital admission to estimate both in-hospital mortality and the risk of death in the 6 months following discharge. It is recommended by the European Society of Cardiology (ESC) and the American College of Cardiology/American Heart Association (ACC/AHA) for guiding the timing of invasive coronary assessment.
How the GRACE score is calculated
Points are assigned to each of the eight input variables using validated lookup tables, then summed. Age contributes 0 to 100 points (older age carries more risk). Heart rate contributes 0 to 46 points (tachycardia increases risk; very slow rates do not). Systolic blood pressure contributes 0 to 58 points in an inverse relationship (hypotension at presentation is a strong adverse sign). Serum creatinine contributes 1 to 28 points reflecting renal impairment. Killip class contributes 0 to 59 points, with cardiogenic shock (Class IV) being the heaviest single contributor. Three binary variables add fixed points: cardiac arrest at admission (39 points), ST-segment deviation on the ECG (28 points), and elevated cardiac enzymes or troponin (14 points). The maximum theoretical score exceeds 370, though scores above 250 are uncommon in practice.
Interpreting the result and clinical implications
Risk is classified as low, intermediate, or high using separate thresholds for in-hospital and 6-month outcomes, and the thresholds differ between NSTEMI/UA and STEMI (see the reference table). For NSTEMI/UA patients, a GRACE score above 140 identifies a high-risk group with in-hospital mortality above 3%, and current ESC guidelines recommend early invasive coronary angiography within 24 hours for this group. Scores between 109 and 140 represent intermediate risk and warrant individualized timing. Scores below 109 support a conservative or delayed invasive approach. For STEMI, the score complements the primary reperfusion decision rather than guiding its timing, which is always emergent. The GRACE score does not account for every clinical nuance: bleeding risk, frailty, patient preferences, and local resources all remain important inputs to the final management decision.
GRACE score vs. TIMI and other ACS tools
The GRACE score consistently outperforms simpler tools such as the TIMI score in head-to-head validation studies for predicting mortality, largely because it incorporates continuous vital-sign variables (heart rate, blood pressure) rather than binary cut-offs, and because it was derived from a broad, unselected registry population rather than a clinical-trial cohort. The TIMI score has the advantage of simplicity (seven yes/no items, scored 0-7) and remains widely used, particularly in emergency settings. A newer GRACE 2.0 model, published in 2014, uses non-linear spline transformations for the continuous variables and enables 1-year and 3-year predictions in addition to 6-month estimates; this calculator implements the well-validated original GRACE 1.0 tabular model, which is still the one embedded in most bedside point-of-care apps and risk-score references.
GRACE score risk categories by ACS type
| ACS Type | Setting | Score Range | Risk | Estimated Mortality |
|---|---|---|---|---|
| NSTEMI/UA | In-hospital | <109 | Low | <1% |
| NSTEMI/UA | In-hospital | 109-140 | Intermediate | 1-3% |
| NSTEMI/UA | In-hospital | >140 | High | >3% |
| NSTEMI/UA | 6-month | <89 | Low | <3% |
| NSTEMI/UA | 6-month | 89-118 | Intermediate | 3-8% |
| NSTEMI/UA | 6-month | >118 | High | >8% |
| STEMI | In-hospital | <126 | Low | <2% |
| STEMI | In-hospital | 126-154 | Intermediate | 2-5% |
| STEMI | In-hospital | >154 | High | >5% |
| STEMI | 6-month | <100 | Low | <4.5% |
| STEMI | 6-month | 100-127 | Intermediate | 4.5-11% |
| STEMI | 6-month | >127 | High | >11% |
Mortality thresholds differ between NSTEMI/UA and STEMI. The same score carries different absolute risk in each setting.
Frequently asked questions
What does a GRACE score above 140 mean?
A GRACE score above 140 is classified as high risk in NSTEMI/UA patients, corresponding to estimated in-hospital mortality above 3%. ESC 2023 and ACC/AHA 2025 ACS guidelines recommend early invasive coronary angiography within 24 hours for this group. For STEMI the high-risk threshold is above 154, though reperfusion is always emergent regardless of score.
What are the 8 variables in the GRACE score?
The eight variables are: (1) age, (2) resting heart rate on admission, (3) systolic blood pressure on admission, (4) serum creatinine, (5) Killip class (a graded assessment of heart failure from none to cardiogenic shock), (6) whether cardiac arrest occurred at admission, (7) whether there is ST-segment deviation on the ECG, and (8) whether cardiac enzymes or troponin are elevated. Each is assigned points from validated lookup tables and the points are summed.
What is the Killip class and how do I determine it?
Killip class grades cardiac function on admission using clinical signs. Class I means no evidence of heart failure (no rales, no raised jugular venous pressure). Class II means mild heart failure with pulmonary rales in the lower lung fields or raised JVP. Class III means established pulmonary edema with widespread rales. Class IV means cardiogenic shock with hypotension, cold peripheries, and signs of tissue hypoperfusion. The Killip class contributes the most points of any single variable at the high end (59 points for Class IV).
Can the GRACE score be used for STEMI?
Yes, but in STEMI the primary goal is immediate reperfusion (thrombolysis or primary PCI) and the score should not delay that decision. In STEMI, GRACE is more useful for prognostication and for decisions about secondary interventions. The risk-category thresholds for STEMI are different from those for NSTEMI/UA: in-hospital low risk is below 126, intermediate is 126-154, and high is above 154.
What is the difference between in-hospital and 6-month GRACE risk?
In-hospital risk reflects mortality during the index hospital stay, driven heavily by the acuity of the presentation (cardiogenic shock, cardiac arrest, haemodynamic instability). Six-month risk reflects longer-term prognosis after discharge and incorporates factors such as renal function and age that have a stronger influence over months than days. A patient can have a low in-hospital risk but intermediate 6-month risk, or vice versa, which is why reporting both is clinically useful.
Does the GRACE score replace clinical judgment?
No. The GRACE score is a decision-support tool that quantifies risk from a fixed set of variables. It does not capture bleeding risk, frailty, patient preferences, contraindications to anticoagulation or invasive procedures, or the quality of local catheterization facilities. Guidelines consistently state that risk scores should inform, not override, individualized clinical assessment.
How does creatinine unit conversion work in this calculator?
Serum creatinine can be entered in either mg/dL (commonly used in the United States) or umol/L (common in the United Kingdom, Canada, and Australia). The calculator converts umol/L to mg/dL by dividing by 88.42 before looking up the point value. To double-check: a creatinine of 88 umol/L is approximately 1.0 mg/dL.