Surgical Risk Assessment Tools

Cardiac Risk Assessment

The American College of Cardiology recommends the Revised Cardiac Risk Index (RCRI) as the most extensively validated tool for predicting major adverse cardiac events (MACE) post-operatively, with six independent predictors: ischemic heart disease, heart failure, cerebrovascular disease, insulin-dependent diabetes, renal dysfunction, and high-risk surgery 1
The RCRI stratifies patients into risk categories: 0 factors (low risk, <1% MACE), 1 factor (low-moderate risk), 2 factors (moderate risk), and ≥3 factors (high risk) 2
The American College of Surgeons NSQIP Myocardial Infarction and Cardiac Arrest (MICA) risk calculator provides potentially superior predictive discrimination in some populations 3
The American University of Beirut (AUB) HAS2 cardiovascular risk index is a newer tool that stratifies patients into low (score 0-1), intermediate (score 2-3), and high risk (score >3) based on 6 clinical elements 4

The European Society for Clinical Nutrition and Metabolism (ESPEN) recommends the Nutritional Risk Screening (NRS-2002) for both elective surgical and critically ill patients 5
Other validated nutritional screening tools include the Subjective Global Assessment (SGA), which incorporates patient history and physical examination, the Nutrition Risk Index, developed specifically for cancer patients, and the Perioperative Nutrition Score, validated to predict adverse postoperative outcomes 5, 6
The Global Leadership Initiative on Malnutrition developed a 2-step approach for diagnosing malnutrition that has been validated as both sensitive and specific 5, 6

Functional capacity assessment is a reliable predictor of perioperative and long-term cardiac events, with the Duke Activity Status Index (DASI) recommended to be combined with risk scores for better stratification 1, 3
Poor functional capacity (inability to achieve 4 METs) indicates increased risk of perioperative adverse cardiovascular events 3
B-type natriuretic peptide (BNP) levels can provide additional risk stratification beyond standard risk scores, with the American Heart Association suggesting that biomarker assessment (BNP/NT-proBNP) may be reasonable for additional risk stratification (Class 2a recommendation) 2, 3

For low-risk patients (RCRI 0-1), the American College of Cardiology recommends proceeding with standard monitoring during surgery 1
For high-risk patients (RCRI ≥3), comprehensive cardiac monitoring and consideration of surveillance for myocardial injury after noncardiac surgery are recommended 3
Combining multiple assessment tools (e.g., RCRI with functional capacity assessment) provides more comprehensive risk stratification than any single tool alone 1, 2, 3
No single risk score has been definitively proven superior to others for all surgical populations, with risk scores having poorer discrimination in patients undergoing vascular surgery 3