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Background: The Global Registry of Acute Coronary Events (GRACE) risk score is widely recommended for risk assessment in patients with acute coronary syndrome (ACS). Aim. To assess the utility of this score for risk prediction in unselected patients with ACS and whether it might be improved by the integration of inflammatory biomarkers and 2D-echocardiography combined with lung ultrasound (LUS) assessment of B-lines (also called ultrasound lung comets). We studied the added value of high sensitivity C-Reactive protein (hs-CRP), and integrated cardio-pulmonary ultrasound to standard clinical markers alone in a multi-parametric approach.Methods: On admission, the GRACE risk score, hs-CRP, 2D-Echo score and LUS (Ejection Fraction, Tricuspid Annular Plane Systolic Excursion and B-lines) were evaluated in 450 patients (age 71±12 yrs) with ACS. The composite end point of in-hospital and post-discharge death or myocardial infarction was evaluated.Results. During a median follow-up of 5 months (interquartile range 1-11), 94 hard events occurred. Receiver operating characteristic analysis showed an area under the curve of 0.753 for the GRACE risk score (p<.0001), 0.770 for the GRACE risk score+hs-CRP (p<.0001), 0.801 for the GRACE risk score+hs-CRP+B-lines (p<.0001) and 0.821 for the GRACE risk score+hs-CRP+Echo score (p<.0001) in predicting the composite end-point. The addition of hs-CRP, B-lines and/or Echo score to the GRACE risk score improved global fit, discriminatory capacity and calibration of the model (p=.0022): see figure.Conclusions: In patients with ACS, addition of hs-CRP, LUS and/or integrated cardiopulmonary ultrasound to the clinical GRACE risk score improved risk stratification.