Calc Function

    • Calcs that help predict probability of a diseaseDiagnosis
    • Subcategory of 'Diagnosis' designed to be very sensitiveRule Out
    • Disease is diagnosed: prognosticate to guide treatmentPrognosis
    • Numerical inputs and outputsFormula
    • Med treatment and moreTreatment
    • Suggested protocolsAlgorithm

    Disease

    Select...

    Specialty

    Select...

    Chief Complaint

    Select...

    Organ System

    Select...

    Patent Pending

    Save your unit preferences in settings!

    Revised Cardiac Risk Index for Pre-Operative Risk

    Estimates risk of cardiac complications after noncardiac surgery.
    Favorite

    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).

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