What is the comparison between the American Heart Association (AHA) guidelines and the Revised Cardiac Risk Index (RCRI) for perioperative clearance in patients with atrial fibrillation (Afib) or atrial flutter?

From the Guidelines

The American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend using the Revised Cardiac Risk Index (RCRI) over the American University of Beirut (AUB-HAS2) score for perioperative cardiovascular risk prediction in noncardiac surgery. The RCRI is a simple, validated, and commonly used tool to assess perioperative risk of major cardiac complications, with modest risk discrimination for cardiac events in patients undergoing noncardiac surgery 1. The RCRI evaluates six independent risk factors, including high-risk surgery, history of ischemic heart disease, history of congestive heart failure, history of cerebrovascular disease, insulin-dependent diabetes, and preoperative serum creatinine >2.0 mg/dL. Some key points to consider when using the RCRI include:

• The RCRI has been more extensively validated across diverse surgical populations compared to the AUB-HAS2 score 1.
• The RCRI has demonstrated good predictive value for major adverse cardiac events, with scores of 0,1,2, and ≥3 corresponding to cardiac complication risks of approximately 0.4%, 1%, 2.4%, and 5.4%, respectively.
• The AUB-HAS2 score, while easily calculated and used to assess 30-day event risk, has not achieved the same level of widespread adoption or validation as the RCRI 1.
• Other risk-prediction tools, such as the Surgical Outcome Risk Tool and the universal NSQIP surgical risk calculator, may provide superior predictive discrimination, but the RCRI remains a practical and widely accepted tool for routine preoperative cardiac risk stratification 1.

From the Research

Comparison of Aub2 and RCRI in Perioperative Clearance

• The Revised Cardiac Risk Index (RCRI) is a widely used tool for predicting perioperative cardiovascular risk in non-cardiac surgery patients 2.
• The RCRI score is based on five independent clinical determinants: history of ischemic heart disease, history of cardiovascular disease, heart failure, insulin-dependent diabetes mellitus, and chronic renal failure 2.
• Studies have shown that the RCRI has high negative predictive value in identifying patients at low risk for perioperative adverse cardiovascular events, but its accuracy is suboptimal in many clinical settings 2, 3.
• Other risk scores, such as the Vascular events In noncardiac Surgery patIents cOhort evaluatioN (VISION) and the Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM), have been developed to improve perioperative risk stratification 2.
• The clinical utility of the RCRI in elderly patients undergoing non-cardiac surgery has been evaluated, with results showing that the RCRI can identify patients at higher risk of perioperative complications, prolonged hospital stay, and higher hospital cost 3, 4.
• However, the correlation between RCRI score and perioperative major adverse cardiac events (MACE) was found to be poor in elderly patients with coronary heart disease undergoing non-cardiac surgery, suggesting the need for a better cardiac risk assessment method for this population 4.

Limitations of RCRI

• The RCRI has been shown to have limited accuracy in predicting perioperative cardiac risk in certain patient populations, such as those with coronary heart disease 4.
• The RCRI does not take into account other important risk factors, such as the indication for surgery, which has been shown to be an independent predictor of 1-year mortality in patients undergoing open infrainguinal bypass vascular surgery 5.
• The use of the RCRI in clinical practice is still scarce, despite its recommendation by European guidelines for risk stratification 2.

Alternative Risk Scores

• The Aub2 score is not mentioned in the provided evidence, suggesting that it may not be a widely used or established risk score for perioperative clearance.
• Other risk scores, such as the Gupta index and the universal surgical risk estimation tool, have been developed to improve perioperative risk stratification, but their comparison to the RCRI is limited 2.