What does this do?
The GRACE 2.0 ACS Risk Calculator is a tool to help clinicians assess the future risk
of death or myocardial infarction (MI), as a guide to treatment options, in a patient
with an acute coronary syndrome (ACS). It includes clinical findings at admission
that have been shown to have predictive power for adverse events (see the
for a complete bibliography).
These factors include age, pulse rate, systolic blood pressure, renal function,
congestive heart failure, ST-segment deviation, cardiac arrest and elevated
biomarkers, which together provide more than 90% of the accuracy of the complete
multivariable prediction model.
Outputs are given in terms of probability of dying (as a percentage) while in
hospital, and at 6 months and 1 and 3 years after admission. The combined risk
of death or MI at 1 year is also given. The GRACE score at 6 months is also provided as
guidelines have categorized patients into low (≤108 GRACE score), medium
(109–140 GRACE score) and high risk (>140 GRACE score) (ESC Guideline on non-STE ACS 2011. Eur Heart J 2011;32:2999–3054).
Why would I use it?
Risk calculators are designed to integrate important risk factors.
The GRACE 2.0 ACS Risk Calculator can provide clinicians with a robust
risk of death or death/MI for the patient presenting with ACS, to help
guide the use of more intensive and invasive therapies. The GRACE Risk
Score has been extensively and independently validated.
The current updated version of the calculator provides more accurate
non-linear computations and an updated interface for mobile devices.
What is different?
This version of the GRACE 2.0 ACS Risk Calculator takes account of
the non-linear relationship of certain risk factors, and now
includes 1-year and 3-year risk calculations. The 1- and 3-year
calculations are particularly relevant for long-term clinical
management, and they have been validated externally against the FAST-MI
Emphasis is given to the probability of an event occurring
(shown as percent risk of death or death/MI in the period),
but for reference to prior studies and guidelines the GRACE
risk score is also provided where applicable.
To help users understand the context of a result, the updated
calculator also provides the population histograms from the
GRACE registry, indicating where the individual patient’s
result is positioned compared with the whole ACS population.
This allows the clinician to determine at a glance whether an
individual’s risk is low, medium or high.
In addition, it is recognized that some evaluations may not
be available (serum creatinine and Killip class) at the time
a risk score is required. For the NICE Guideline on non-ST
elevation ACS a "mini" version of the GRACE score was tested in a population of
approximately 70,000 patients. It performed well compared
with all published scores. This option is automatically
implemented when creatinine or Killip is not available
(see I don’t have creatinine/Killip data).
How do I enter data?
To calculate the GRACE risk for any patient with documented or
suspected ACS, enter the patient data by selecting from the
ranges given or by using the yes/no toggle switches. Press
"Calculate" to obtain risk of event probabilities, or "Reset"
to clear all entered data.
On the results screen, use "Edit input" to change individual
parameters for the same patient, or "New calculation" to reset
the calculator and start over.
What is CHF/Killip?
Killip is a classification of congestive heart failure (CHF)
that independently predicts mortality in patients with MI.
For the purposes of the calculator it includes prior history or current CHF.
The Killip classification:
||No clinical sign of CHF
||Presence of rales (crackles) in the lungs, raised jugular venous pressure, or third heart sound (S3 gallop)
||Acute pulmonary oedema
What are the creatinine units?
Creatinine values are displayed in both US and SI units
(mg dL⁻¹ and μmol L⁻¹, respectively)
for your convenience.
I don't have creatinine/Killip data
The most accurate result is obtained using actual Killip class and serum
creatinine level values, but if you do not have these data then select
"Not available". You will then be able to enter substitute values: either
presence of renal failure in place of serum creatinine or use of
diuretics (either current or historical) in place of Killip class.
The calculator will automatically default to the "mini-GRACE" algorithm
with results that are nearly as accurate as the full GRACE risk calculation.
The "mini-GRACE" algorithm will be employed whenever either serum creatinine
or Killip class is unavailable.
What is troponin?
Troponin is a protein found in heart cells that is released into the
bloodstream following cardiac damage. Elevated troponin in the
bloodstream on admission is a strong predictor of mortality and infarct size.
If troponin data are not available then cardiac biomarkers of myocardial
necrosis (sometimes known as "cardiac enzymes", for example CK-MB or CK)
may be substituted.
What do the results mean?
The results are given first as a probability (expressed as a percentage)
of either death alone, or death/MI, occurring up to given time points
after admission. The original GRACE score is also provided for 6-month results.
Why is a range quoted?
Because of differences in the way the 6-month and 1-year probabilities
are calculated (see What are its limitations?), and to reflect
the differences in original risk populations, a range of probabilities
may be quoted.
Where is the GRACE numerical score?
Previous versions of the GRACE ACS Risk Score Calculator yielded
numerical "scores", which then had to be converted to probabilities.
In this version, risks are given directly as probabilities for ease
of interpretation. While users already familiar with the calculator
may be comfortable with the GRACE score, a probability is more
intuitive and easier to understand in context. Additionally, the
1- and 3-year calculations yield a probability directly from linear
and non-linear terms, resulting in greater predictive accuracy
than can be obtained using a score.
Because nomograms for in-hospital and 6-month death and death/MI
are calculated from different patient datasets, with differing
risk factor estimates (and because estimates determine the
risk score), it is impossible to relate the scores at the
different time points to each other in the same patient.
However, the probability of an event will always increase over
time, and so probability gives a more easily understandable
insight into how the different clinical parameters might affect
long-term risk. For the benefit of users familiar with the previous
version of the calculator, we have retained the original GRACE
score for 6-month results.
What do the graphs show?
The graphs (currently only available for 1 and 3 years) are derived
from the entire GRACE population of 102,341 patients, and show the
distribution of risk for the entire ACS population.
The vertical bar on the graph indicates the calculated probability
of an event for the individual patient result, superimposed over
the full range of the GRACE ACS population. The number on top
gives the calculated probability, while the bar changes colour,
from green to yellow to red, depending on the risk tertile for
that particular patient. This allows the practitioner to determine
at a glance whether their patient has a low, medium or high risk,
and is intended as a guide to inform clinical management of patients.
In the app, use the "Back" button to return to the tabulated output.
What are its limitations?
The new 1-year and 3-year calculations are based on clinical
observations across the entire GRACE ACS population.
In addition, for greater accuracy, the updated score takes
account of the non-linear relationship between some factors
and risk. The in-hospital and 6-month calculations did not
have access to the entire dataset, and so it is not possible
to directly compare the shorter-term with the longer-term
outputs for any given patient. For this reason, the 6-month
results in this version of the calculator are adjusted to
reflect overall death rates in the different populations.
This explains why the 6-month results in this version are
not identical to the probabilities given by the original
Additionally, the 6-month calculation is based on a
score-based model, which is converted to a probability.
This is less accurate than calculating the probability
directly. Together with the difference in original risk
populations this may result in the 6-month probability
being greater than at 1 year for some patients. When this
occurs the risk is quoted as a range between the two
However, as the calculator is designed to facilitate
management of patients suffering an ACS, the small
differences that these uncertainties introduce are,
from a clinical point of view, largely irrelevant.
To guide clinical therapeutic decision making, the
most important factor to know is whether a given
patient is in the lowest, middle or upper tertile of
risk, as indicated by the graphs.
This version includes death/MI calculations only at
1 year. It is considered that 1 year is the most
clinically relevant time point, but further outputs
will be enabled once the calculator has been fully
validated against external databases.
Who made this?
The updated calculator is derived from the
original GRACE score.
The work on the updated calculator was supported by the British
Heart Foundation, the Chief Scientist in Scotland and an
educational grant from AstraZeneca to the University of
Edinburgh (chair of the GRACE Advisory Committee, Professor
Keith AA Fox at the University of Edinburgh). Professors Frederick A Anderson, Jr. and Gordon FitzGerald of the Center for Outcomes Research, University of Massachusetts Medical School, analysed the GRACE population risk factors
and created the algorithms. The algorithms were implemented
and the app and website created by AS&K Communications.
For more information, bibliography and GRACE score contact information please visit the
GRACE database homepage
at the University of Massachusetts Medical School, and GRACE Score at the University of Edinburgh.