Clinicians assessing cardiac risk as part of a comprehensive consultation before surgery can use an expanding set of tools, including predictive risk calculators, cardiac stress tests and measuring serum natriuretic peptides. The optimal assessment strategy is unclear, with conflicting international guidelines. We investigated the prognostic accuracy of the Revised Cardiac Risk Index for risk stratification and cardiac outcomes in patients undergoing elective non-cardiac surgery in a contemporary Australian cohort. We audited the records for 1465 consecutive patients 45 years and older presenting to the perioperative clinic for elective non-cardiac surgery in our tertiary hospital. We calculated individual Revised Cardiac Risk Index scores and documented any use of preoperative cardiac tests. The primary outcome was any major adverse cardiac events within 30 days of surgery, including myocardial infarction, pulmonary oedema, complete heart block or cardiac death. Myocardial perfusion imaging was the most common preoperative stress test (4.2%, 61/1465). There was no routine investigation of natriuretic peptide levels for cardiac risk assessment before surgery. Major adverse cardiac events occurred in 1.3% (18/1366) of patients who had surgery. The Revised Cardiac Risk Index score had modest prognostic accuracy for major cardiac complications, area under receiver operator curve 0.73, 95% confidence interval 0.60 to 0.86. Stratifying major adverse cardiac events by the Revised Cardiac Risk Index scores 0, 1, 2 and 3 or greater corresponded to event rates of 0.6% (4/683), 0.8% (4/488), 4.1% (6/145) and 8.0% (4/50), respectively. The Revised Cardiac Risk Index had only modest predictive value in our single-centre experience. Patients with a revised cardiac risk index score of 2 or more had an elevated risk of early cardiac complications after elective non-cardiac surgery.
Background Myocardial perfusion imaging (MPI) is frequently used for cardiac risk assessment before major non‐cardiac surgery, but its ability to improve patient risk classification beyond simple clinical assessment is unknown. Aim To explore the prognostic utility of MPI above a simple clinical risk calculator, the revised cardiac risk index (RCRI). Methods A retrospective cohort study of at‐risk patients who underwent MPI before major non‐cardiac surgery in a tertiary hospital was conducted. Major adverse cardiac events (MACE) was defined as any myocardial infarction, acute pulmonary oedema, ventricular arrhythmia or cardiac death within 30 days of surgery. We analysed the predictive value of MPI for MACE using multivariable logistic regression and categorical net reclassification index. Results MACE occurred in 47 (7.4%) cases from 635 surgical procedures in 629 patients. MPI‐identified medium or large‐sized reversible perfusion defects (P = 0.02; odds ratio 2.9; 95% confidence interval 1.1–7.1) and RCRI score two or more (P = 0.03; odds ratio 2.3; 95% confidence interval 1.1–4.8) were significantly associated with MACE after adjusting for age, coronary revascularisation, surgical priority, need for general anaesthesia, left ventricular ejection fraction (LVEF) and fixed perfusion defects. MPI risk factors (LVEF, reversible perfusion and fixed perfusion defects) did not improve risk classification above baseline risk factors (age, RCRI and surgical priority). Conclusion MPI risk factors are weak predictors for early cardiac complications after major non‐cardiac surgery and failed to improve patient risk classification beyond essential assessment using age, RCRI and surgical priority. Clinicians should consider alternative risk assessment strategies because of MPI's poor prognostic utility and its associated time and financial costs.
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