External validation of the GRACE risk score and the risk-treatment paradox in patients with acute coronary syndrome

Niels M R van der Sangen*, Jaouad Azzahhafi, Dean R P P Chan Pin Yin, Joyce Peper, Senna Rayhi, Ronald J Walhout, Melvyn Tjon Joe Gin, Deborah M Nicastia, Jorina Langerveld, Georgios J Vlachojannis, Rutger J van Bommel, Yolande Appelman, José P S Henriques, Jurriën M Ten Berg, Wouter J Kikkert

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review

2 Citations (Web of Science)


OBJECTIVES: To validate the Global Registry of Acute Coronary Events (GRACE) risk score and examine the extent and impact of the risk-treatment paradox in contemporary patients with acute coronary syndrome (ACS).

METHODS: Data from 5015 patients with ACS enrolled in the FORCE-ACS registry between January 2015 and December 2019 were used for model validation. The performance of the GRACE risk score for predicting in-hospital and 1-year mortality was evaluated based on indices of model discrimination and calibration. Differences in the delivery of guideline-recommended care among patients who survived hospitalisation (n=4911) per GRACE risk stratum were assessed and the association with postdischarge mortality was examined.

RESULTS: Discriminative power of the GRACE risk score was good for predicting in-hospital (c-statistic: 0.86; 95% CI: 0.83 to 0.90) and 1-year mortality (c-statistic: 0.82; 95% CI: 0.79 to 0.84). However, the GRACE risk score overestimated the absolute in-hospital and 1-year mortality risk (Hosmer-Lemeshow goodness-of-fit test p<0.01). Intermediate-risk and high-risk patients were 12% and 29% less likely to receive optimal guideline-recommended care compared with low-risk patients, respectively. Optimal guideline-recommended care was associated with lower mortality in intermediate- and high-risk patients.

CONCLUSIONS: The GRACE risk score identified patients at higher risk for in-hospital and 1-year mortality, but overestimated absolute risk levels in contemporary patients. Optimal guideline-recommended care was associated with lower mortality in intermediate-risk and high-risk patients, but was less likely to be delivered with increasing mortality risk.

Original languageEnglish
Article number001984
Number of pages11
JournalOpen Heart
Issue number1
Publication statusPublished - Mar 2022


  • Acute Coronary Syndrome/diagnosis
  • Aftercare
  • Humans
  • Patient Discharge
  • Registries
  • Risk Assessment
  • Risk Factors
  • ESC

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