Revised Cardiac Risk Index for Pre-Operative Risk

According to the 2017 CCS Perioperative Guidelines:

• If the RCRI is ≥1, the patient’s age is ≥65, or they are between 45-64 years old with significant cardiac disease, consider obtaining NT-proBNP or BNP.

• If the NT-proBNP is ≥300 ng/L or BNP is ≥92 ng/L, then an EKG should be ordered in the PACU, and troponins should be measured daily for 48-72 hours.

• If, after risk stratification, the NT-proBNP is <300 ng/L or BNP <92 ng/L, no routine postoperative cardiac monitoring is recommended.

• If these assays are not available, then patients should be monitored with an EKG in the PACU and troponin measurements daily for 48-72 hours if they meet any one of the following additional criteria: known history of coronary artery disease, cerebral vascular disease, peripheral artery disease, heart failure, severe pulmonary hypertension, or a severe obstructive intracardiac abnormality (e.g., severe aortic stenosis, severe mitral stenosis, or severe hypertrophic obstructive cardiomyopathy).

The data supporting the use of NT-proBNP/BNP comes from a large 2014 meta-analysis of 18 studies with a total of 2,477 patients (Rodseth 2014). This study, which was in agreement with multiple previous meta-analyses, noted that for patients with a pre-operative NT-proBNP of <300 ng/L or BNP <92 ng/L, the rate of 30-day postoperative non-fatal MI or death was 4.9% (3.9%-61%), and was 21.8% (19.0%-24.8%) in those with pre-operative NT-proBNP is ≥300 ng/L or BNP is ≥92 ng/L.