The GRACE Score’s Performance in Predicting In-Hospital and 1-Year Outcome in the Era of High-Sensitivity Cardiac Troponin Assays and B-Type Natriuretic Peptide

Study Questions:

What is the change in accuracy of GRACE score if high-sensitivity troponin assay is used for the risk stratification of patients with acute coronary syndrome (ACS)?


The authors compared the accuracy of the GRACE score that was derived using the conventional cardiac troponin (cTn) assays, with that calculated with high-sensitivity cTn (hs-cTn), and with the combination of the GRACE score with hs-cTn or B-type natriuretic peptide (BNP). The conventional assay was used for clinical care decisions.


The study cohort was comprised of 370 patients, of whom 173 had unstable angina and 197 had an acute myocardial infarction. In-hospital mortality was 4.1%, and the 1-year mortality was 12.5%. The GRACE score was significantly higher in patients who died compared with those discharged alive (200 vs. 125, p < 0.001), and in those who died at 1 year (151 vs. 104, p < 0.001). The area under the curve (AUC) of the GRACE score was 0.87 regarding in-hospital mortality and 0.88 for 1-year mortality. There was no change in the AUC if calculated with hs-cTn (0.87 and 0.88, respectively). Similarly, no improvement in the long-term accuracy of the GRACE model was noted with use of hs-cTn or BNP.


The authors concluded that the GRACE score is highly accurate for predicting outcome of patients with ACS. Addition of hs-cTn or BNP did not increase the predictive ability of the GRACE score.


GRACE score has consistently demonstrated excellent discrimination for identifying ACS patients at risk of death (Aragam et al., PLoS One 2009;4:e7947). This study again establishes the high accuracy of the GRACE score, and also demonstrates limited additive prognostic value of biomarkers for identifying patients at risk of death. The high-sensitivity troponin assays are superior to conventional troponin assays for identifying patients presenting with chest pain who are at risk for myocardial infarction, and this study does not negate their utility for that purpose in any fashion.

Clinical Topics: Acute Coronary Syndromes, ACS and Cardiac Biomarkers

Keywords: Acute Coronary Syndrome, Biological Markers, Troponin, Natriuretic Peptide, Brain

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