Perioperative Cardiac Risk Assessment

Introduction to RCRI

The American Heart Association recommends using the Revised Cardiac Risk Index (RCRI) to predict perioperative cardiac complications in non-cardiac surgery, with rates of 0.4-0.5%, 0.9-1.3%, 4-7%, and 9-11% for patients with 0, 1, 2, or ≥3 risk factors respectively 1, 2

A history of ischemic heart disease is an independent predictor of major adverse cardiac events (MACE) in non-cardiac surgery, as defined by the RCRI 1
A history of congestive heart failure is an independent predictor of MACE in non-cardiac surgery, as defined by the RCRI 1
A history of cerebrovascular disease is an independent predictor of MACE in non-cardiac surgery, as defined by the RCRI 1, 2
High-risk surgery, such as intraperitoneal, intrathoracic, or suprainguinal vascular procedures, is an independent predictor of MACE in non-cardiac surgery, as defined by the RCRI 1, 2
Preoperative insulin treatment for diabetes mellitus is an independent predictor of MACE in non-cardiac surgery, as defined by the RCRI 1, 2
Preoperative serum creatinine >2.0 mg/dL is an independent predictor of MACE in non-cardiac surgery, as defined by the RCRI 1

Patients with an RCRI score of 0 are considered low risk, with a <1% risk of MACE, and can proceed directly to surgery without additional cardiac testing 3
Patients with an RCRI score of 1 are considered low-moderate risk, with a 0.9-1.3% risk of MACE, and can proceed to surgery without additional testing 3
Patients with an RCRI score of 2 are considered moderate risk, with a 4-7% risk of MACE, and should consider functional capacity assessment and additional testing if poor functional capacity (<4 METs) and results would change management 3, 5
Patients with an RCRI score of ≥3 are considered high risk, with a 9-11% risk of MACE, and should implement comprehensive cardiac monitoring and consider surveillance for myocardial injury after non-cardiac surgery 5, 4

For patients with an RCRI score of 0-1, the American College of Cardiology recommends proceeding directly to surgery without additional cardiac testing, continuing chronic beta-blockers and statins, and considering 12-lead ECG if established cardiovascular disease is present 3
For patients with an RCRI score of 2, the American College of Cardiology recommends assessing functional capacity, and considering pharmacological stress testing only if results would change management 5
For patients with an RCRI score of ≥3, the American College of Cardiology recommends comprehensive cardiovascular examination, correcting anemia if hematocrit <28%, and considering pharmacological stress testing if poor functional capacity and results would impact management 5