Neutrophil to lymphocyte ratio (NLR) as an indicator of systemic inflammation has been linked to morbidity and mortality in Acute coronary syndrome (ACS). Global Registry of Acute Coronary Events (GRACE) score is recommended by recent guidelines for risk stratification and prognosis of ACS cases. This research aimed to study NLR and its relationship to GRACE Score in ACS cases. Methods: This cross-sectional study was performed on 120 cases, aged ≥ 18 years, with ACS either ST elevation acute myocardial infarction (STEMI), non-ST elevation acute myocardial infarction (NSTEMI), or unstable angina (UA), clinically confirmed through ischemic symptoms and electrocardiography (ECG) changes. Cases underwent further subdivision into three equal groups: STEMI group, NSTEMI group, and UA group. All cases underwent laboratory investigations (complete blood count (CBC), cardiac markers (troponin-I). Every patient underwent GRACE risk score calculation. Results: NLR was significantly lower in low GRACE group than Intermediate and high GRACE group (P value <0.001) and in intermediate than high GRACE group (P Value=0.002). There was a positive correlation between NLR and GRACE score (r= 0.521, P value < 0.001). NLR can significantly predict high and intermediate grace score (P <0.001 and AUC = 0.755) at cut-off >5.9 with 66.15% sensitivity, 81.82% specificity, 81.1% PPV and 67.2% NPV. NLR can significantly predict high grace score (P<0.001 and AUC =0.801) at cut-off >8.2 with 74.07% sensitivity, 79.57% specificity, 51.3% PPV and 91.4% NPV. Conclusion: NLR has a positive correlation with the GRACE Score in ACS cases and modest prediction to high GRACE score.