Minimizing Cardiac Risk in Patients with High RCRI Scores Undergoing Non-cardiac Surgery

Understanding the RCRI and Risk Stratification

The American College of Cardiology recommends using the RCRI, a validated tool for estimating perioperative risk of major cardiac complications, with six independent risk factors: ischemic heart disease, heart failure, cerebrovascular disease, high-risk surgery, insulin-dependent diabetes, and renal dysfunction 1, 2
Risk increases with the number of factors present: 0 factors (low risk, <1% MACE), 1 factor (low-moderate risk), 2 factors (moderate risk), and ≥3 factors (high risk) 3

The American College of Cardiology suggests determining surgery urgency, as emergent surgery may not allow for extensive cardiac evaluation, and identifying active cardiac conditions that may require postponing elective surgery: unstable coronary syndromes, decompensated heart failure, significant arrhythmias, and severe valvular disease 4, 5
A comprehensive cardiovascular examination, including vital signs, carotid pulse assessment, jugular venous pressure, lung auscultation, and peripheral vascular examination, is recommended 1
Obtaining a 12-lead ECG for patients with established cardiovascular disease or symptoms is advised 2

Evaluating functional capacity using tools like the Duke Activity Status Index (DASI) is recommended, as poor functional capacity (<4 METs) indicates increased risk 3, 6
Considering biomarker assessment (BNP/NT-proBNP) for additional risk stratification is suggested 2, 3
Correcting anemia if present, as hematocrits <28% are associated with increased perioperative ischemia and complications, is recommended 1, 5

For patients with poor or unknown functional capacity, considering pharmacological stress testing (dobutamine stress echocardiogram or myocardial perfusion imaging) if results would change management is advised 2
Routine preoperative coronary angiography is not recommended 2

Continuing beta-blockers in patients who are on them chronically for Class I guideline indications is recommended 2
For high-risk patients not on beta-blockers, considering initiating them more than 1 day before surgery to assess safety and tolerability is suggested 2
Monitoring for hypotension, bradycardia, or bleeding postoperatively and modifying beta-blocker dosing as needed is advised 2
Continuing statins in patients currently taking them is recommended 2
Continuation of ACE inhibitors or ARBs is reasonable perioperatively 2

For high-risk patients (RCRI ≥3), implementing comprehensive cardiac monitoring during surgery is recommended 3
Considering postoperative surveillance for myocardial injury after non-cardiac surgery (MINS) is suggested 3

For thoracic surgery patients, the Thoracic Revised Cardiac Risk Index (ThRCRI) may be more appropriate 2, 6