Management of Patients with Low Cardiac Risk Undergoing Non-cardiac Surgery

Understanding Cardiac Risk Stratification

The American Heart Association/American College of Cardiology recommends that patients with a Revised Cardiac Risk Index (RCRI) score of 0-1 are classified as low risk, with a predicted major adverse cardiovascular events (MACE) risk of <1% 1

The American Heart Association/American College of Cardiology recommends that patients with low risk of perioperative MACE can proceed directly to surgery without additional cardiac testing 2
The American Heart Association/American College of Cardiology suggests considering guideline-directed medical therapy (GDMT) initiation for long-term cardiovascular risk reduction and disease management as applicable 3

The American Heart Association/American College of Cardiology recommends that a 12-lead ECG is reasonable in patients with established cardiovascular disease or symptoms (Class 2a recommendation) 3
The American Heart Association/American College of Cardiology recommends continuing beta blockers in patients who are on beta blockers chronically (Class I recommendation) 4
The American Heart Association/American College of Cardiology recommends continuing statins in patients currently taking statins (Class I recommendation) 4
The American Heart Association/American College of Cardiology suggests that continuation of ACE inhibitors or ARBs is reasonable perioperatively (Class IIa recommendation) 4

The American Heart Association/American College of Cardiology recommends considering whether further testing would impact decision-making or perioperative care for patients with poor or unknown functional capacity (Duke Activity Status Index <34, METs <4) 3
The American Heart Association/American College of Cardiology suggests that biomarker assessment (BNP/NT-proBNP) may be reasonable for additional risk stratification (Class 2a recommendation) 3

The American College of Cardiology recommends using the Revised Cardiac Risk Index (RCRI) as a validated tool for estimating perioperative risk of major cardiac complications in patients undergoing non-cardiac surgery, with moderate discriminative ability 5, 6

The RCRI predicts the risk of major cardiac complications after non-cardiac surgery, including myocardial infarction, pulmonary edema, ventricular fibrillation or primary cardiac arrest, and complete heart block 5, 7, 8
The RCRI includes six independent predictors of risk, such as history of ischemic heart disease, history of cerebrovascular disease, and preoperative insulin treatment for diabetes mellitus 9

The American Heart Association suggests that the risk of major cardiac complications increases with the number of risk factors present, with RCRI 0-1 indicating low risk (<1% risk of MACE) and RCRI 2-3 indicating elevated risk (≥1% risk of MACE) 5, 10

The American College of Surgeons recommends using the RCRI as an initial screening tool before proceeding to more specialized cardiac testing, and to guide perioperative management decisions 6, 8, 11
For patients with RCRI ≥2, consider additional risk assessment, including functional capacity evaluation, and specialized cardiac testing if it would change management 5, 7, 11, 12

Emergency surgery increases cardiac risk regardless of RCRI score, according to the American College of Cardiology 5, 10
Combining RCRI with other assessments may enhance risk prediction, as suggested by the American Heart Association 11

The American College of Cardiology recommends additional cardiac evaluation for patients with a Revised Cardiac Risk Index (RCRI) score of 2, based on functional capacity assessment, with pharmacological stress testing if functional capacity is poor or unknown and would impact management decisions 13, 14

The American College of Cardiology suggests a preoperative resting 12-lead ECG is reasonable for patients with known coronary heart disease or other significant structural heart disease 13, 14
Assessment of left ventricular function is reasonable for patients with dyspnea of unknown origin or heart failure with worsening symptoms 14
Routine preoperative evaluation of LV function is not recommended without specific indications 14

For patients with RCRI score of 2 and excellent functional capacity (≥4 METs), the American College of Cardiology recommends proceeding to surgery without further evaluation 13, 14
For patients with RCRI score of 2 and poor (<4 METs) or unknown functional capacity, determine if further testing would impact decision-making or perioperative care 13, 14
Exercise testing may be reasonable to assess functional capacity if it would change management 14

If functional capacity is poor or unknown, pharmacological stress testing (dobutamine stress echocardiogram or myocardial perfusion imaging) is reasonable if it will change management 13, 14
Routine preoperative coronary angiography is not recommended 13, 14

The American College of Cardiology recommends continuing beta blockers in patients who are on beta blockers chronically for conditions with Class I guideline indications 15
In patients with RCRI score of 2 who are not on beta blockers, it may be reasonable to begin beta blockers before surgery, preferably more than 1 day before surgery to assess safety and tolerability 15
Management of beta blockers after surgery should be guided by clinical circumstances, with attention to modifying or temporarily discontinuing them as needed for hypotension, bradycardia, or bleeding 15

The American College of Chest Physicians suggests that the Thoracic Revised Cardiac Risk Index (ThRCRI) may be more appropriate for patients undergoing thoracic surgery, though some studies question its accuracy 16

The European Society of Cardiology recommends that an RCRI score of 2 places a patient in the moderate-risk category, with approximately 7% risk of major cardiac complications 17
The American Heart Association classifies cranioplasty as intermediate-risk surgery, which influences the decision pathway 18

The European Society of Cardiology suggests documenting the specific RCRI risk factors present, such as ischemic heart disease, heart failure, cerebrovascular disease, insulin-dependent diabetes, chronic kidney disease, or high-risk surgery 17

The American Heart Association states that neurological history and previous cranial surgeries do not independently modify cardiac risk assessment algorithms 18
The American Heart Association notes that the intermediate-risk classification of cranioplasty means many patients with RCRI 2 can proceed safely without extensive testing 18