The revised cardiac risk index for preoperative risk may be used in patients ≥45 years old (or 18–44 years with significant cardiovascular disease*) undergoing elective non-cardiac surgery or urgent/semi-urgent (non-emergent) non-cardiac surgery.

*Known history of ischemic heart disease, cerebrovascular disease, peripheral arterial disease, congestive heart failure, severe pulmonary hypertension, or severe obstructive intracardiac abnormality (eg, severe aortic stenosis, severe mitral stenosis, or severe hypertrophic obstructive cardiomyopathy).

NB! The RCRI score should be used with caution in patients requiring urgent surgery, as this scale is not well validated in this population.

The revised cardiac risk index for preoperative risk accurately risk-stratifies patients and helps patients understand individualized risk prior to undergoing surgery, which can be helpful in discussions of informed consent.

In patients with elevated risk (RCRI ≥1, age ≥65, or age 45-64 with significant cardiovascular disease), helps direct further preoperative risk stratification (e.g. with serum NT-proBNP or BNP) and determine appropriate cardiac monitoring post-op (ECG, troponins).

*Known history of coronary artery disease, cerebral vascular disease, peripheral artery disease, congestive heart failure, severe PHTN or a severe obstructive intracardiac abnormality (e.g. severe aortic stenosis, severe mitral stenosis, or severe hypertrophic obstructive cardiomyopathy).

Interpretation:

According to the 2016 CCS Perioperative Guidelines:

• If the RCRI is ≥1, the patient’s age is ≥65, or they are between 45-64 with significant cardiac disease*, the next step is to measure the patient’s NT-ProBNP or BNP if this is available at your institution.
• If the NT-ProBNP is ≥300 ng/L or BNP is ≥92 ng/L, then there should be an EKG ordered in the PACU and troponins should be measured daily for 48-72 hours.
• If, after risk stratification, the NT-ProBNP is <300 ng/L or BNP <92 ng/L, no routine postoperative cardiac monitoring is warranted.
• If the institution does not have these assays available, then all patients should be monitored with an EKG in the PACU and troponin measurements daily for 48-72 hours if they meet one of the following: RCRI ≥1, age ≥65, or age 45-64 with the aforementioned cardiac disease.*

*Known history of coronary artery disease, cerebral vascular disease, peripheral artery disease, congestive heart failure, severe PHTN or a severe obstructive intracardiac abnormality (e.g. severe aortic stenosis, severe mitral stenosis, or severe hypertrophic obstructive cardiomyopathy).

The data supporting the use of NT-ProBNP/BNP comes from a large 2014 meta-analysis of 18 studies with a total of 2,477 patients (Rodseth 2014). This study, which was in agreement with multiple previous meta-analyses, noted that for those patients with a pre-operative NT-ProBNP of <300 ng/l or BNP <92 ng/l, the rate of 30-day postoperative non-fatal MI or Death was 4.9% (3.9%-61%), and was 21.8% (19.0%-24.8%) in those with pre-operative NT-ProBNP is ≥300 ng/L or BNP is ≥92 ng/L.

RCRI score easy to use by any involved specialty, including general internal medicine, cardiology, anesthesia, or surgery, and very well validated. It can be used in the inpatient or outpatient preoperative setting.

At the same time, the RCRI score includes a limited number of risk factors it includes, in part because the original studies could not include a sufficient number of patients for every important risk factor (e.g. underestimates hemodynamic and cardiovascular outcomes in valvular disease).

NB! Other patient important outcomes that are not assessed by this tool include:

• risk of stroke,
• major bleeding,
• prolonged hospitalization,
• ICU admission.

Alternative perioperative cardiac risk scores like the Myocardial Infarction and Cardiac Arrest (MICA) Score and the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) Score have been validated only retrospectively and therefore underestimate the risk of myocardial ischemia compared with the RCRI, which has been validated by multiple studies over the past 15 years including a very large 2010 systematic review (24 studies and 792,740 patients) which found moderate discrimination in predicting major perioperative cardiac complications.

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Literature

1. Goldman L, Caldera DL, Nussbaum SR, Southwick FS, Krogstad D, Murray B, Burke DS, O’Malley TA, Goroll AH, Caplan CH, Nolan J, Carabello B, Slater EE. Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med. 1977 Oct 20;297(16):845-50. https://pubmed.ncbi.nlm.nih.gov/904659/
2. Lee TH, Marcantonio ER, Mangione CM, Thomas EJ, Polanczyk CA, Cook EF, Sugarbaker DJ, Donaldson MC, Poss R, Ho KK, Ludwig LE, Pedan A, Goldman L. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. 1999 Sep 7;100(10):1043-9. https://pubmed.ncbi.nlm.nih.gov/10477528/
3. VISION Pilot Study investigators, Devereaux PJ, Bradley D, Chan MT, et al. An international prospective cohort study evaluating major vascular complications among patients undergoing noncardiac surgery: the VISION Pilot Study. Open Med. 2011;5(4):e193-200. https://pubmed.ncbi.nlm.nih.gov/22567075/
4. Ausset S, Auroy Y, Lambert E, et al. Cardiac troponin I release after hip surgery correlates with poor long-term cardiac outcome. Eur J Anaesthesiol. 2008;25(2):158-64. https://pubmed.ncbi.nlm.nih.gov/17666156/
5. Sheth T, Chan M, Butler C, et al. Prognostic capabilities of coronary computed tomographic angiography before non-cardiac surgery: prospective cohort study. BMJ. 2015;350:h1907. https://pubmed.ncbi.nlm.nih.gov/25902738/
6. Ford MK, Beattie WS, Wijeysundera DN. Systematic review: prediction of perioperative cardiac complications and mortality by the revised cardiac risk index. Ann Intern Med. 2010;152(1):26-35. http://www.ncbi.nlm.nih.gov/pubmed/20048269
7. Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) Developed in Collaboration With the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. J Am Coll Cardiol. 2007;50(17):1707-32. https://pubmed.ncbi.nlm.nih.gov/17950159/
8. Duceppe E, Parlow J, Macdonald P, et al. Canadian Cardiovascular Society Guidelines on Perioperative Cardiac Risk Assessment and Management for Patients Who Undergo Noncardiac Surgery. Can J Cardiol. 2017;33(1):17-32. https://pubmed.ncbi.nlm.nih.gov/27865641/
9. Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130(24):2215-2245. https://pubmed.ncbi.nlm.nih.gov/25085962/
10. Rajagopalan S, Croal BL, Bachoo P, Hillis GS, Cuthbertson BH, Brittenden J. N-terminal pro B-type natriuretic peptide is an independent predictor of postoperative myocardial injury in patients undergoing major vascular surgery. J Vasc Surg. 2008;48(4):912-7. https://pubmed.ncbi.nlm.nih.gov/18586440/
11. Rodseth RN, Biccard BM, Le manach Y, et al. The prognostic value of pre-operative and post-operative B-type natriuretic peptides in patients undergoing noncardiac surgery: B-type natriuretic peptide and N-terminal fragment of pro-B-type natriuretic peptide: a systematic review and individual patient data meta-analysis. J Am Coll Cardiol. 2014;63(2):170-80. https://pubmed.ncbi.nlm.nih.gov/24076282/
12. Devereaux PJ, Duceppe E, Guyatt G, et al. Dabigatran in patients with myocardial injury after non-cardiac surgery (MANAGE): an international, randomised, placebo-controlled trial. Lancet. 2018;391(10137):2325-2334. https://pubmed.ncbi.nlm.nih.gov/29900874/

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