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    Gupta Perioperative Risk for Myocardial Infarction or Cardiac Arrest (MICA)

    Predicts risk of MI or cardiac arrest after surgery.
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    INSTRUCTIONS

    Use within 30 days of surgery (pre- or postoperatively). May be used in cardiac or noncardiac procedures.

    When to Use
    Pearls/Pitfalls
    Why Use

    • Use in patients undergoing surgery, within 30 days of surgery (pre- or postoperatively).

    • May be used in cardiac or noncardiac procedures.

    • Improves on prior perioperative major cardiac event risk calculators for surgical patients by using datasets built on modern standards of care in cardiac event assessment (e.g. troponin vs. CK-based markers), in addition to stratifying risk based on type of planned procedure.

    • The criteria for myocardial ischemia was new troponin elevation >3 times the upper limit of normal, which may exclude some myocardial infarctions.

    • Tends to underestimate cardiac events in patients with elevated risk.

    • Useful in patients undergoing low risk procedures, or who are anticipated to require <2 days admission.

    • Pulmonary edema and complete heart block, outcomes for previous perioperative cardiac risk calculators, were not part of the NSQIP database from which this calculator was derived.

    • Few (<1%) of patients suffer perioperative major cardiac events, but 30-day mortality in this population is high (61%).

    • Identifying higher risk patients who will benefit from pre-operative medical cardiac optimization is important.

    • Also useful in preoperative counseling and discussions of informed consent.

    • Recommended as a validated risk estimation tool by 2014 ACC/AHA guidelines on perioperative cardiac evaluation, alongside the ACS NSQIP risk estimator and the Revised Cardiac Risk Index.

    • May be more accurate than RCRI in lower-risk patients (Cohn 2018).

    years
    Independent
    Partially dependent
    Totally dependent
    1: normal healthy patient
    2: mild systemic disease
    3: severe systemic disease
    4: severe systemic disease that is a constant threat to life
    5: moribund, not expected to survive without surgery
    Normal (≤1.5 mg/dL, 133 µmol/L)
    Elevated (>1.5 mg/dL, 133 µmol/L)
    Unknown
    Choose one

    Result:

    Please fill out required fields.

    Next Steps
    Evidence
    Creator Insights

    Advice

    May help determine which patients require additional post-surgical cardiac monitoring.

    Management

    • Patients identified as low risk require no further cardiovascular testing, according to ACC/AHA guidelines.

    • Patients identified as high risk may require additional cardiovascular evaluation, including cardiology consultation, stress testing, and/or echocardiogram.

    Critical Actions

    Patients with known or suspected heart disease (cardiovascular disease, significant valvular disease, symptomatic arrhythmias) should undergo routine preoperative cardiac evaluation if indicated for the proposed surgery.

    Formula

    Cardiac risk, % = ex / (1 + ex)

    Where x = −5.25 + sum of the values of the selected variables:

    Variable Options

    Value

    Functional status

    Independent

    0

    Partially dependent

    0.65

    Totally dependent

    1.03

    ASA class

    1: normal healthy patient

    −5.17

    2: mild systemic disease

    −3.29

    3: severe systemic disease

    −1.92

    4: severe systemic disease that is a constant threat to life

    −0.95

    5: moribund, not expected to survive without surgery

    0

    Creatinine

    Normal (≤1.5 mg/dL, 133 µmol/L)

    0

    Elevated (>1.5 mg/dL, 133 µmol/L)

    0.61

    Unknown

    −0.10

    Age per year of increase

     

    Age × 0.02

    Type of surgery

    Anorectal

    −0.16

    Aortic

    1.60

    Bariatric

    −0.25

    Brain

    1.40

    Breast

    −1.61

    Cardiac

    1.01

    ENT*

    0.71

    Foregut or hepatopancreatobiliary**

    1.39

    Gallbladder, appendix, adrenals or spleen

    0.59

    Hernia

    0

    Intestinal

    1.14

    Neck

    0.18

    Obstetric/gynecologic

    0.76

    Orthopedic

    0.80

    Other abdomen

    1.13

    Peripheral vascular***

    0.86

    Skin

    0.54

    Spine

    0.21

    Thoracic

    0.40

    Vein

    −1.09

    Urology

    −0.26

    *ENT and head and neck surgeries except thyroid and parathyroid.

    **Esophagus, stomach, duodenum, pancreas, liver, and biliary tree (except isolated cholecystectomy).

    ***Nonaortic, nonvein vascular surgeries.

    Evidence Appraisal

    Gupta et al (2011) used the NSQIP database to identify risk factors associated with intra- or postoperative MI or cardiac arrest in over 200,000 patients. Compared with other risk calculators, the Gupta Perioperative Risk Score (also sometimes called the MICA or Myocardial Infarction/Cardiac Arrest Score) factors in higher usage of minimally invasive surgery and differentiates between organ system and type of surgery. However, this score was only validated retrospectively, and therefore likely underestimates myocardial ischemia. Further, stress test results and beta-blocker therapy status were not a part of the NSQIP database data used to derive this score.

    Like the Gupta Score, the ACS NSQIP Surgical Risk Calculator predicts either myocardial infarction or cardiac arrest within 30 days of surgery, and has been shown to perform well in patients undergoing low-risk procedures or those with a shorter duration length of stay. The Gupta Score selects fewer patients as elevated risk compared to the ACS NSQIP Surgical Risk Calculator or the RCRI. RCRI tends to overestimate risk in lower risk patients; therefore, it is suggested to use ACS NSQIP or Gupta Score calculators for that group of patients (Cohn 2018).

    Literature

    Other References

    Research PaperLee TH, Marcantonio ER, Mangione CM, Thomas EJ, Polanczyk CA, Cook EF, Sugarbaker DJ, Donaldson MC, Poss R, Ho KK, Ludwig LE, Pedan A, Goldman L. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation 1999;100:1043-1049.Research PaperBilimoria KY, Liu Y, Paruch JL, Zhou L, Kmiecik TE, Ko CY, Cohen ME. Development and evaluation of the universal ACS NSQIP surgical risk calculator: a decision aid and informed consent tool for patients and surgeons. J. Am Coll Surg 2013;217;833-842, e831-e833.Research PaperDavis C, Tait G, Carroll J, Wijeysundera DN, Beattie WS. The Revised Cardiac Risk Index in the new millennium: a single-centre prospective cohort re-evaluation of the original variables in 9,519 consecutive elective surgical patients. Can J Anaesth 2013;60:855–863.Research PaperCohn SL, Fernandez ros N. Comparison of 4 Cardiac Risk Calculators in Predicting Postoperative Cardiac Complications After Noncardiac Operations. Am J Cardiol. 2018;121(1):125-130.
    Dr. Prateek K. Gupta

    About the Creator

    Prateek K. Gupta, MD, is a vascular surgeon at Methodist University Hospital in Memphis, Tennessee. He is also an assistant professor of surgery at the University of Tennessee. Dr. Gupta's primary research interest is surgical outcomes.

    To view Dr. Prateek K. Gupta's publications, visit PubMed

    Content Contributors
    • Alice Race, MD
    Reviewed By
    • Ram Kolachalam, MD
    About the Creator
    Dr. Prateek K. Gupta
    Content Contributors
    • Alice Race, MD
    Reviewed By
    • Ram Kolachalam, MD