The Global Registry of Acute Coronary Event (GRACE) risk score was developed in a
large multinational registry to predict in-hospital mortality across the broad spectrum
of acute coronary syndromes (ACS). Because of the substantial regional variation and
temporal changes in patient characteristics and management patterns, we sought to
validate this risk score in a contemporary Canadian population with ACS.
The main GRACE and GRACE(2) registries are prospective, multicenter, observational
studies of patients with ACS (June 1999 to December 2007). For each patient, we calculated
the GRACE risk score and evaluated its discrimination and calibration by the c statistic
and the Hosmer-Lemeshow goodness-of-fit test, respectively. To assess the impact of
temporal changes in management on the GRACE risk score performance, we evaluated its
discrimination and calibration after stratifying the study population into prespecified
subgroups according to enrollment period, type of ACS, and whether the patient underwent
coronary angiography or revascularization during index hospitalization.
A total of 12,242 Canadian patients with ACS were included; the median GRACE risk
score was 127 (25th and 75th percentiles were 103 and 157, respectively). Overall,
the GRACE risk score demonstrated excellent discrimination (c statistic 0.84, 95%
CI 0.82-0.86, P < .001) for in-hospital mortality. Similar results were seen in all
the subgroups (all c statistics >/=0.8). However, calibration was suboptimal overall
(Hosmer-Lemeshow P = .06) and in various subgroups.
GRACE risk score is a valid and powerful predictor of adverse outcomes across the
wide range of Canadian patients with ACS. Its excellent discrimination is maintained
despite advances in management over time and is evident in all patient subgroups.
However, the predicted probability of in-hospital mortality may require recalibration
in the specific health care setting and with advancements in treatment.