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    Revised Cardiac Risk Index for Pre-Operative Risk

    Estimates risk of cardiac complications after noncardiac surgery.
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    INSTRUCTIONS

    Note: this content was updated January 2019 to reflect the substantial body of evidence, namely external validation studies, suggesting that the original RCRI had significantly underestimated the risk (see Evidence for more).

    When to Use
    Pearls/Pitfalls
    Why Use

    • Patients ≥45 years old (or 18-44 years old with significant cardiovascular disease) undergoing elective non-cardiac surgery or urgent/semi-urgent (non-emergent) non-cardiac surgery.

    • Use with caution in emergency surgery patients, as the score is not as well validated in this population.

    • Easy to use by any involved specialty, including general internal medicine, cardiology, anesthesia, or surgery, and very well validated.

    • Can be used in the inpatient or outpatient preoperative setting.

    • Includes a limited number of risk factors it includes, in part because the original studies could not include a sufficient number of patients for every important risk factor (e.g. underestimates hemodynamic and cardiovascular outcomes in valvular disease).

    • Other patient important outcomes that are not assessed by this tool include risk of stroke, major bleeding, prolonged hospitalization, and ICU admission.

    • Accurately risk-stratifies patients and helps patients understand individualized risk prior to undergoing surgery, which can be helpful in discussions of informed consent.

    • In patients with elevated risk (RCRI ≥1, age ≥65, or age 45-64 with significant cardiovascular disease), helps direct further preoperative risk stratification (e.g. with serum NT-proBNP or BNP) and determine appropriate cardiac monitoring post-op (EKG, troponins).

    • Alternative perioperative cardiac risk scores like the Myocardial Infarction and Cardiac Arrest (MICA) Score and the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) Score have been validated only retrospectively and therefore underestimate the risk of myocardial ischemia (Duceppe 2017, Rodseth 2014, Devereaux 2011) compared with the RCRI, which has been validated by multiple studies over the past 15 years including a very large 2010 systematic review (24 studies and 792,740 patients) which found moderate discrimination in predicting major perioperative cardiac complications (Ford 2010).

    No
    0
    Yes
    +1
    No
    0
    Yes
    +1
    No
    0
    Yes
    +1
    No
    0
    Yes
    +1
    No
    0
    Yes
    +1
    No
    0
    Yes
    +1

    Result:

    Please fill out required fields.

    Next Steps
    Evidence
    Creator Insights

    Advice

    According to the 2016 CCS Perioperative Guidelines:

    • If the RCRI is ≥1, the patient’s age is ≥65, or they are between 45-64 with significant cardiac disease*, the next step is to measure the patient’s NT-ProBNP or BNP if this is available at your institution.

    • If the NT-ProBNP is ≥300 ng/L or BNP is ≥92 ng/L, then there should be an EKG 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 warranted.

    • If the institution does not have these assays available, then all patients should be monitored with an EKG in the PACU and troponin measurements daily for 48-72 hours if they meet one of the following: RCRI ≥1, age ≥65, or age 45-64 with the aforementioned cardiac disease.*

    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 those 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.

    *Known history of coronary artery disease, cerebral vascular disease, peripheral artery disease, congestive heart failure, severe PHTN or a severe obstructive intracardiac abnormality (e.g. severe aortic stenosis, severe mitral stenosis, or severe hypertrophic obstructive cardiomyopathy).

    Formula

    Addition of the selected points:

    Risk factor

    Description

    Points

    High-risk surgery

    Intraperitoneal; intrathoracic; suprainguinal vascular

    +1

    History of ischemic heart disease

    History of myocardial infarction (MI); history of positive exercise test; current chest pain considered due to myocardial ischemia; use of nitrate therapy or ECG with pathological Q waves

    +1

    History of congestive heart failure

    Pulmonary edema, bilateral rales or S3 gallop; paroxysmal nocturnal dyspnea; chest x-ray (CXR) showing pulmonary vascular redistribution

    +1

    History of cerebrovascular disease

    Prior transient ischemic attack (TIA) or stroke

    +1

    Pre-operative treatment with insulin

    --

    +1

    Pre-operative creatinine >2 mg/dL / 176.8 µmol/L

    --

    +1

    Facts & Figures

    Interpretation:

    RCRI Score

    Risk of major cardiac event (95% CI)*

    0

    3.9% (2.8-5.4%)

    1

    6.0% (4.9-7.4%)

    2

    10.1% (8.1-12.6%)

    ≥3

    15% (11.1-20.0%)

    *Defined as death, myocardial infarction, or cardiac arrest at 30 days after noncardiac surgery (from Duceppe 2017).

    Evidence Appraisal

    Since the original study was published by Goldman et al in 1977, a systematic review by Ford et al (2010) including 792,740 patients from 24 studies found the RCRI showed risk of major cardiovascular events (including death) was 2-10 times higher than previously reported. There are two drivers of this effect: the routine use of high-sensitivity cardiac troponin over creatinine kinase, and the inclusion of validation studies that enrolled patients undergoing emergent surgery. It revealed moderate discrimination of major perioperative cardiac complications between low and high risk patients. The RCRI did not perform well in predicting death in all-comers, due to high heterogeneity between studies, and cardiovascular events in patients undergoing vascular surgery.

    Beyond this systematic review, data from a total of four prospective studies and one retrospective study were combined to calculate the pooled event rates for each of the RCRI scores (Duceppe 2017). Only one of the studies, the VISION Pilot Study, actually had the goal of prospectively validating the RCRI.

    The VISION Pilot Study is a large, multicenter, international prospective cohort study of 432 adults >45 years old who underwent noncardiac surgery with either regional or general anesthetic. All patients had their troponin measured post-operatively in the PACU and daily for 72 hours. The primary composite outcome was vascular death, nonfatal MI, non-fatal cardiac arrest, and nonfatal strokes. One objective of the study was to prospectively validate the RCRI criteria using a composite outcome of MI, pulmonary edema, ventricular fibrillation, and complete heart block. The event rates based on RCRI criteria were 2.2% for an RCRI of 0, 8.2% for RCRI of 1, 5.3% for an RCRI of 2, and 36.4% for an RCRI of ≥3.

    Rajagopalan et al (2008) prospectively collected NT-ProBNP as well as troponins measured immediately after surgery and on postoperative days 1, 2, 3, and 5 in a cohort of 136 patients undergoing elective vascular surgery for AAA or sub-critical limb ischemia. The objective of the study was to assess the efficacy of NT-ProBNP elevation as a predictor of elevated troponins. Their primary outcome was elevation of troponin-I >0.1 ng/mL . The data had appropriate patient characteristics and endpoints and therefore event rates could be calculated based on RCRI scores and included in the pooled estimates (Duceppe 2017; Sheth 2015).

    Ausset et al (2008) prospectively measured troponin levels in 88 patients undergoing elective hip surgery on postoperative days 1, 2, and 3. Positive elevation in troponin level was noted to be 0.08 ng/mL. All patients had their RCRI calculated and event rates were displayed in the results. Interestingly, the study went on to assess whether these elevated troponin measurement were associated with major cardiac events within the first year following surgery and they showed that 45.5% of patients with elevated troponins in the first 3 days following surgery had major cardiac events, while only 3.9% of those who did not have elevated troponins did.

    Sheth et al (2015), in association with the Coronary CTA VISION study group, published a large international multicentre prospective cohort study in which 955 patients with (or at risk of) CAD undergoing non-cardiac surgery. Each patient had preoperative coronary CTA in order to assess if burden of stenosis seen on CTA was a useful predictor of perioperative cardiovascular death and MI within 30 days of surgery. RCRI data was collected for each patient and therefore rates of outcome could be stratified by RCRI data and included in the pooled estimate. Vast over-estimation of risk in those who did not have events was demonstrated.

    Myocardial injury in non-cardiac surgery (MINS), defined as cardiac biomarker elevation post-surgically, is an important prognostic marker. Studies consistently show increased risk of cardiovascular outcomes and mortality both in the short-term and long-term. This prompted the 2018 RCT of dabigatran in patients with MINS (MANAGE) which revealed an absolute risk reduction from 15% to 11% with 110 mg BID of dabigatran in the composite outcome: major vascular complication, a composite of vascular mortality and non-fatal myocardial infarction, non-haemorrhagic stroke, peripheral arterial thrombosis, amputation, and symptomatic venous thromboembolism (Devereaux 2018).

    The likely explanation for these differences is that the original RCRI study monitored creatine kinase muscle and brain isoenzyme (CK-MB) and excluded emergency surgery patients, whereas the external validation studies monitored troponin measurements that are much more sensitive than creatine kinase muscle and brain isoenzyme, and some studies included emergency surgery patients.

    A large scale external validation using 34,000 patients and update of the renal variable is underway using data from the VISION study by the Population Health Research Institute (PHRI) at McMaster University. The trial registration is currently available: https://bmjopen.bmj.com/content/7/1/e013510.

    Literature

    Validation

    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 Sep 7;100(10):1043-9.Research PaperVISION Pilot Study investigators, Devereaux PJ, Bradley D, Chan MT, et al. An international prospective cohort study evaluating major vascular complications among patients undergoing noncardiac surgery: the VISION Pilot Study. Open Med. 2011;5(4):e193-200.Research PaperAusset S, Auroy Y, Lambert E, et al. Cardiac troponin I release after hip surgery correlates with poor long-term cardiac outcome. Eur J Anaesthesiol. 2008;25(2):158-64.Research PaperSheth T, Chan M, Butler C, et al. Prognostic capabilities of coronary computed tomographic angiography before non-cardiac surgery: prospective cohort study. BMJ. 2015;350:h1907.Research PaperFord MK, Beattie WS, Wijeysundera DN. Systematic review: prediction of perioperative cardiac complications and mortality by the revised cardiac risk index. Ann Intern Med. 2010;152(1):26-35.

    Clinical Practice Guidelines

    Research PaperFleisher LA, Beckman JA, Brown KA, et al. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) Developed in Collaboration With the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. J Am Coll Cardiol. 2007;50(17):1707-32.Research PaperDuceppe E, Parlow J, Macdonald P, et al. Canadian Cardiovascular Society Guidelines on Perioperative Cardiac Risk Assessment and Management for Patients Who Undergo Noncardiac Surgery. Can J Cardiol. 2017;33(1):17-32.

    Other References

    Research PaperRajagopalan S, Croal BL, Bachoo P, Hillis GS, Cuthbertson BH, Brittenden J. N-terminal pro B-type natriuretic peptide is an independent predictor of postoperative myocardial injury in patients undergoing major vascular surgery. J Vasc Surg. 2008;48(4):912-7.Research PaperRodseth RN, Biccard BM, Le manach Y, et al. The prognostic value of pre-operative and post-operative B-type natriuretic peptides in patients undergoing noncardiac surgery: B-type natriuretic peptide and N-terminal fragment of pro-B-type natriuretic peptide: a systematic review and individual patient data meta-analysis. J Am Coll Cardiol. 2014;63(2):170-80.Research PaperDevereaux PJ, Duceppe E, Guyatt G, et al. Dabigatran in patients with myocardial injury after non-cardiac surgery (MANAGE): an international, randomised, placebo-controlled trial. Lancet. 2018;391(10137):2325-2334.
    Dr. Lee Goldman

    From the Creator

    Dr. Lee Goldman on original Goldman Cardiac Risk Index for MDCalc:

    The Revised Cardiac Risk Index was published 22 years after the original index became the first multifactorial approach to assessing the cardiac risk of non-cardiac surgery and one of the first such approaches for any common clinical problem. The revision was important because of major changes in the diagnosis of cardiac disease during the intervening years – especially the widespread use of echocardiography and less use of Holter monitoring. As a result, evidence of coronary disease and heart failure replaced prior reliance on the arrhythmias (both atrial and ventricular) that had been very important in the original index. Furthermore, the original index changed practice, so that previously important factors (recent MI, severe aortic stenosis) were rarely represented in the more recent cohort of patients. We had hoped that the Index would not only estimate risk but also help target certain subgroups of patients for specific beneficial interventions. The former goal has been achieved, as numerous studies have validated the Index, even if some have suggested ways to improve it in certain types of patients. The latter goal has been more elusive, since large randomized trials have failed to show benefits from preoperative coronary revascularization or perioperative beta blockade, or by extension the preoperative testing that might refine risk stratification. Whether some high risk subgroups will benefit from any of these strategies remain a subject of debate.

    About the Creator

    Lee Goldman, MD, MPH, is a professor and executive vice president for Health and Biomedical Sciences at Columbia University. He is also the dean of the Faculties of Health Sciences and Medicine at Columbia University Medical Center. Previously, he was a professor, department chair and associate dean at UCSF. Dr. Goldman researches the costs and effectiveness of diagnostic and therapeutic strategies and is well-known for applying the latest methods of multivariate analysis, cost-effectiveness, quality-of-life, and computer-simulation models to key topics in clinical medicine.

    To view Dr. Lee Goldman's publications, visit PubMed

    Content Contributors
    • Elliot Hepworth, MD
    • Reza Mirza, MD
    About the Creator
    Dr. Lee Goldman
    Content Contributors
    • Elliot Hepworth, MD
    • Reza Mirza, MD