Cardiac risk assessment with the Revised Cardiac Risk Index index before elective non-cardiac surgery: A retrospective audit from an Australian tertiary hospital

Abstract

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.

Myocardial perfusion imaging failed to improve patient risk classification compared with the revised cardiac risk index for early cardiac complications after major non‐cardiac surgery

“…The Canadian Cardiovascular Society Guidelines recommend initial cardiac risk screening with the RCRI and further risk assessment by measuring serum natriuretic peptides 12 . The RCRI has modest predictive ability for MACE 11 with poor performance in vascular surgery 10 . There have been attempts to improve on the RCRI, such as the Vascular Quality Initiative cardiac risk index; however, these risk calculators still only have modest predictive ability 26,27 .…”

“…[4][5][6][7][8] The revised cardiac risk index (RCRI) is a simple risk calculator with modest prognostic accuracy for major cardiac complications after non-cardiac surgery. [9][10][11] The RCRI contains six risk factors, each scoring one point towards the calculated score (Table 1). A RCRI score of two or more carries a significant increase in risk for major adverse cardiac events (MACE).…”

“…The revised cardiac risk index (RCRI) is a simple risk calculator with modest prognostic accuracy for major cardiac complications after non‐cardiac surgery 9–11 . The RCRI contains six risk factors, each scoring one point towards the calculated score (Table 1).…”

Postoperative Myocardial Infarction after Non-Cardiac Surgery: An Update

“…The 2016 guidelines of the Canadian Cardiovascular Society recommend risk stratification using the RCRI (Revised Cardiac Risk Index), a risk calculator for people over 45 years of age [ 16 ]. Only six variables are required for the risk to be quantified: a high-risk type of surgery including intrathoracic surgery, intraperitoneal surgery, and supra femoral vascular procedures, the presence of ischemic heart disease, the presence of congestive heart failure, cerebrovascular disorders, diabetes requiring insulin, and preoperative serum creatinine >2 mg/dL [ 17 ]. For each risk factor, 1 point is assigned.…”