Revised Cardiac Risk Index for Pre-operative Risk
Estimates risk of cardiac complications after noncardiac surgery
Examples: intraperitoneal, intrathoracic, suprainguinal, carotid, vascular (aortic and major vascular), head and neck, orthopedic, prostate
Procedures with a risk of major adverse cardiac event (MACE) of death or myocardial infarction (MI) of ≥ 1% are considered elevated risk (see 2014 ACC/AHA Guidelines).
- History of myocardial infarction (MI)
- History of positive exercise test
- Current chest pain considered due to MI
- Use of nitrate therapy
- ECG with pathological Q waves
- Prior transient ischemic attack (TIA) or stroke
- Pulmonary edema, bilateral rales or S3 gallop
- Paroxysmal nocturnal dyspnea
- Chest x-ray (CXR) showing pulmonary vascular redistribution
Reference
Summary
The Revised Cardiac Risk Index (RCRI) for pre-operative risk allows the clinician in the inpatient or outpatient preoperative setting to risk-stratify patients before undergoing a procedure or surgery. However, the score is not as well validated in emergency surgery patients. RCRI can also be a tool to help patients understand their individual risk profile as a part of an informed consent conversation. When patients present with elevated risk (RCRI ≥ 1, age ≥ 65, or age 45-64 with significant cardiovascular disease), additional preoperative risk stratification is provided (e.g. serum NT-proBNP or BNP) along with post-op cardiac monitoring recommendations (e.g. EKG, troponins). The RCRI has been validated by multiple studies. A large 2010 systematic review found moderate discrimination in predicting major perioperative cardiac complications (Ford, 2010). According to Duceppe (2017), other perioperative cardiac risk scores, such as the Myocardial Infarction and Cardiac Arrest (MICA) Score and the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) Score, have only been retrospectively validates and likely underestimates the risk of myocardial ischemia.
.Summary
The Revised Cardiac Risk Index (RCRI) is intended for the following population undergoing elective non-cardiac surgery or urgent/semi-urgent (non-emergent) non-cardiac surgery:
- Patients ≥ 45 years or
- Patients 18-44 years old with significant cardiovascular disease*
*Significant cardiac disease refers to a known history of
- coronary artery disease
- peripheral artery disease
- congestive heart failure
- severe pulmonary hypertension (PHTN)
- severe obstructive intracardiac abnormality (e.g. severe aortic stenosis, severe mitral stenosis or severe hypertrophic obstructive cardiomyopathy)
| Risk Factor | Description | Points |
| Elevated-risk surgery* | Examples: intraperitoneal, intrathoracic, suprainguinal, carotid, head and neck, orthopedic, prostate, vascular (aortic and major vascular) | 1 |
| History of ischemic heart disease | History of myocardial infarction (MI); history of positive exercise test; current chest pain considered due to myocardial ischemia; use of nitrate therapy or ECG with pathological Q waves | 1 |
| History of congestive heart failure | Pulmonary edema, bilateral rales or S3 gallop; paroxysmal nocturnal dyspnea; chest X-ray (CXR) showing pulmonary vascular redistribution | 1 |
| History of cerebral vascular disease | Prior transient ischemic attack (TIA) or stroke | 1 |
| Pre-operative treatment with insulin | 1 | |
| Pre-operative creatinine > 2 mg/dL or 176.8 µmol/L | 1 |
| RCRI Score | Risk of major cardiac event (95% CI)* |
| 0 | 3.9% (2.8-5.4%) |
| 1 | 6.0% (4.9-7.4%) |
| 2 | 10.1% (8.1-12.6%) |
| ≥ 3 | 15% (11.1-20.0%) |
*Defined as death, myocardial infarction, or cardiac arrest at 30 days after noncardiac surgery (Duceppe, 2017).
Management Considerations
One or more of the following criteria have been met:
- RCRI score ≥ 1
- Age ≥ 65
- Age 45-64 with significant cardiac disease
According to the 2016 CCS Perioperative Guidelines:
- Measure the patient's NT-ProBNP or BNP (if available)
- If NT-ProBNP is ≥ 300 ng/L or BNP ≥ 92 ng/L, then order an EKG in the PACU and troponins to be measured daily for 48-72 hours
- If NT-ProBNP is < 300 ng/L or BNP < 92 ng/L (after risk stratification), then no routine postoperative cardiac monitoring is warranted.
- If these assays are not available, then all patients require
- monitoring with an EKG in the PACU and
- troponins to be measured daily for 48-72 hours
Instructions
- Indicated in patients ≥ 45 years old (or 18-44 years old with significant cardiovascular disease) undergoing elective non-cardiac surgery or urgent/semi-urgent (non-emergent) non-cardiac surgery.
- Proceed with caution: The score is not as well validated in emergency surgery patients.
Literature
- Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med. 1977 Oct 20;297(16):845-50. — 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.
- Systematic review: prediction of perioperative cardiac complications and mortality by the revised cardiac risk index. Ann Intern Med. 2010 Jan 5;152(1):26-35. — Ford MK, Beattie WS, Wijeysundera DN.
- Canadian Cardiovascular Society Guidelines on Perioperative Cardiac Risk Assessment and Management for Patients Who Undergo Noncardiac Surgery. Can J Cardiol. 2017 Jan;33(1):17-32. — Duceppe E, Parlow J, MacDonald P, Lyons K, McMullen M, Srinathan S, Graham M, Tandon V, Styles K, Bessissow A, Sessler DI, Bryson G, Devereaux PJ.
- 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 Dec 9;130(24):2215-45. — Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt B, Davila-Roman VG, Gerhard-Herman MD, Holly TA, Kane GC, Marine JE, Nelson MT, Spencer CC, Thompson A, Ting HH, Uretsky BF, Wijeysundera DN.
- Jennifer Glen , DNP, FNP-BC — EVAL Health, Chief Medical Officer