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    • Subcategory of 'Diagnosis' designed to be very sensitiveRule Out
    • Disease is diagnosed: prognosticate to guide treatmentPrognosis
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    Patent Pending

    Revised Cardiac Risk Index for Pre-Operative Risk

    Estimates risk of cardiac complications after noncardiac surgery.

    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).

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    Result:

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    Next Steps
    Evidence
    Creator Insights
    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

    Are you Dr. Lee Goldman? Send us a message to review your photo and bio, and find out how to submit Creator Insights!
    MDCalc loves calculator creators – researchers who, through intelligent and often complex methods, discover tools that describe scientific facts that can then be applied in practice. These are real scientific discoveries about the nature of the human body, which can be invaluable to physicians taking care of patients.
    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