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Introduction Systemic sclerosis (SSc) is associated with increased mortality. Intensive therapies have emerged for severe or refractory cases, but carry significant risks. The RESIST score (Risk score for Early mortality to Stratify for Intensive SSc Therapy) was developed to predict early mortality (<5 years) in patients eligible for such treatments.Material and Methods Using the EUSTAR cohort, patients unsuitable for intensive therapy were excluded. Survival was analyzed via Kaplan–Meier estimates. A multivariable Cox model with adaptive LASSO selection was built, informed by expert opinion, univariable analyses, and literature. Model performance was evaluated using the C-index, area under the curve (AUC) at 3 and 5 years, and calibration. Missing data were imputed, and external validation was performed on 6,251 excluded patients.Results Of 22,059 EUSTAR patients, 4,526 met inclusion criteria; 138 died within five years. Deceased patients were more often male (28% vs. 16%), older (53 vs. 49 years), and had diffuse cutaneous SSc (dcSSc) (61% vs. 35%) compared to survivors. The RESIST score included: male sex; dcSSc; age >55 years; elevated CRP; digital ulcers; modified Rodnan skin score >14; left ventricular ejection fraction <60%; and diffusing capacity of the lungs <60%. This allowed SSc patients to be discriminated into three groups with the following five-year survival rates: low risk (99%, 95% CI: 98-100), intermediate risk (96%, 95% CI: 95-97) and high risk (82%, 95% CI: 78-87).The model showed good discrimination in both the development and discrimination cohorts (AUC: 0.79 [0.77–0.79] and 0.78 [0.77–0.79], respectively).Conclusions The RESIST score reliably predicts early mortality in SSc patients eligible for intensive therapies and may guide treatment decisions by identifying those at high risk of death.Abstract P.366 Table 1