A look into Lee's score: peri-operative cardiovascular risk assessment in non-cardiac surgeries—usefulness of revised cardiac risk index

Abstract

Objective: The revised cardiac risk index (RCRI/Lee's score) was designed for peri-operative risk assessment before elective major non-cardiac surgeries. Through this article, we report the usefulness of RCRI in our daily practice, while evaluating patients undergoing surgeries of varying risk.Methods: Only referred patients, aged ≥ 40 years, were included. Risk stratification was done using RCRI scoring system. Patients were categorised into 4 classes depending on 0, 1, 2, and ≥3 risk predictors (risk predictors were high-risk surgery, history of ischaemic heart disease (IHD), diabetes on insulin, history of stroke (cerebrovascular accident [CVA]), history of congestive heart failure (CHF) and serum creatinine of >2 mg%). Electrocardiograms (ECG) were done in all patients, while troponin I in intermediate and high-risk patients, and in others if symptomatic. Perioperative cardiovascular events were managed appropriately. Results:Of the 920 patients included, only 853 patients were analysed as 67 patients were not operated upon. The mean age was 59 ± 11years and 46% of the patients were women. Two hundred and ninety-two underwent high-risk surgeries, 97 patients had history of IHD, 89 had history of CHF, 36 gave history of CVA, 269 patients were diabetics on insulin and 68 had serum creatinine >2 mg%. Number of patients in Lee's classes I, II, III, and IV were 311, 347, 150, and 52, respectively. 26 out of 853 patients had peri-operative events. Of the six variables in RCRI, only history of IHD was an independent predictor of events. Event rates increased as the RCRI class increased, i.e. 1.7%, 2.0%, 6.7%, and 7.7% for classes I-IV, respectively. Age >70 years, poor general medical condition, emergency surgery and left bundle branch block (LBBB) on ECG, were significantly associated with peri-operative events. Conclusion:The RCRI is a useful tool in pre-operative risk stratification. It should perhaps be further updated to improve its predictive accuracy.

Grade 3 Echocardiographic Diastolic Dysfunction Is Associated With Increased Risk of Major Adverse Cardiovascular Events After Surgery: A Retrospective Cohort Study

“…Romero-Corral et al 23 also reported that, in patients with coronary artery disease, those who were overweight (25–29.9 kg/m 2 ) had lower mortality. In line with previous studies, 14,24 preoperative hypertension, coronary heart disease, arrhythmia, and renal insufficiency were also associated with an increased risk of postoperative MACEs in our patients. Long-term glucocorticoid therapy increases the risk of cardiovascular disease.…”

Pre-operative Cardiovascular Evaluation in elective Noncardiac Surgery, Risk Scores, and Managerial Insight for Patients with Different Cardiac Morbidities

“…The RCRI aims to predict post-operative pulmonary edema, myocardial infarction, ventricular fibrillation or cardiac arrest, and complete heart block. The RCRI used to be considered a very useful cardiacrisk prediction index in noncardiac surgery; however, it was developed years ago and many progressions occurred since then regarding diagnosis and management of cardiovascular diseases [7].…”

“…In clinical practice, risk scores are not implemented unanimously, also these scores should not impose a predetermined management decision systematically, they should rather be regarded as one of the multiple pieces of the puzzle in the pre-operative context. In addition, these risk scores were developed years ago, and none has a perfect predictive value; in this regard, they could be used as complementary risk predictors in a changing medical world [7], [8]. Moreover, they should be used to optimize the pre-operative risk stratification, helping to reduce unnecessary pre-operative paraclinical tests and to apply tailored perioperative management [8].…”

“…Cardiac complications occur more frequently in patients with cardiac conditions such as ischemic heart disease, left ventricular dysfunction, valvular heart disease, or arrhythmias [6]. Demographics of patients undergoing surgery show a trend toward an increasing number of elderly patients and associated comorbidities; moreover, cardiovascular disease is the most frequent comorbidity in elderly patients presenting for general surgery [6], [7].…”

Time spent per patient in lumbar spinal stenosis surgery

“…The RCRI identifies patients at higher risk for cardiovascular complications during noncardiac surgery [13]. It takes into account six independent predictive factors of complications, and it is a useful tool in risk stratification [13,14]. The severe postoperative pain score is a preoperative assessment of pain caused by the procedure based on a patient's previous history.…”