Predicting Major Adverse Cardiac Events Post-Operatively

Introduction to Risk Scores

The Revised Cardiac Risk Index (RCRI) is the most widely validated and recommended risk score for predicting major adverse cardiac events (MACE) post-operatively, according to the American Heart Association, though no single risk score has been definitively proven superior to others 1, 2, 3
The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) perioperative MI and cardiac arrest (MICA) risk calculator may provide superior predictive discrimination in some populations, as suggested by the American College of Surgeons 2, 4
The universal American College of Surgeons NSQIP surgical risk calculator is another option with potentially better discrimination in certain populations, according to the American College of Surgeons 4
The AUB-HAS2 cardiovascular risk index is an easily calculated tool to assess 30-day event risk, as noted by the American College of Cardiology 2

RCRI includes six independent predictors: history of ischemic heart disease, history of heart failure, history of cerebrovascular disease, preoperative insulin treatment for diabetes, preoperative renal dysfunction, and high-risk surgery, as defined by the European Society of Cardiology 5
Patients can be classified by RCRI score: 0 factors (low risk), 1 factor (low to moderate risk), 2 factors (moderate risk), and ≥3 factors (high risk) for major cardiac complications, according to the American College of Cardiology 6, 7

The 2024 AHA/ACC guidelines note that "although many risk scores exist, data are lacking to support the use of one risk index over another", highlighting the need for further research by the American Heart Association and American College of Cardiology 1, 3
Risk scores have poorer discrimination in patients undergoing vascular surgery, likely due to underestimation of cardiac risk, as reported by the American College of Surgeons 4

Functional capacity assessment using the Duke Activity Status Index (DASI) should be combined with risk scores for better stratification, as recommended by the American Heart Association 2, 8
Poor functional capacity (inability to achieve 4 METs) indicates increased risk of perioperative adverse cardiovascular events, according to the American College of Cardiology 2, 6
B-type natriuretic peptide (BNP) levels can provide additional risk stratification beyond standard risk scores, as noted by the American College of Cardiology 6, 7

For low-risk patients (RCRI 0-1), proceeding with standard monitoring during surgery is recommended, according to the American College of Surgeons 7, 8
For high-risk patients (RCRI ≥3), implement comprehensive cardiac monitoring and consider surveillance for myocardial injury after noncardiac surgery (MINS), as suggested by the American Heart Association and American College of Cardiology 6, 8