From the Guidelines
The best perioperative risk assessment tools are the Revised Cardiac Risk Index (RCRI) and the American Society of Anesthesiologists (ASA) Physical Status Classification System, as they provide a simple and validated method for assessing perioperative risk of major cardiac complications, as recommended by the 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline for perioperative cardiovascular management for noncardiac surgery 1. The RCRI is specifically designed for cardiac risk assessment in non-cardiac surgery, evaluating six factors: high-risk surgery, history of ischemic heart disease, history of congestive heart failure, history of cerebrovascular disease, preoperative treatment with insulin, and preoperative serum creatinine >2.0 mg/dL, with higher scores indicating increased cardiac risk 1. The ASA classification is widely used and simple to apply, categorizing patients into six classes based on their overall health status, from ASA I (healthy patient) to ASA VI (brain-dead patient), helping predict perioperative morbidity and mortality risks 1. To use these tools effectively:
- Conduct a thorough patient history and physical examination
- Review recent lab results, especially for renal function and diabetes management
- Consider additional cardiac testing for high-risk patients (e.g., stress tests, echocardiography)
- Use the ASA classification for overall risk and the RCRI for specific cardiac risk
- Communicate the risk assessment results to the entire perioperative team These tools are valuable because they provide standardized, evidence-based methods for risk stratification, allowing for better preoperative optimization, informed consent, and appropriate resource allocation during and after surgery, as supported by the 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline 1.
From the Research
Perioperative Risk Assessment Tools
The following are some of the best perioperative risk assessment tools:
- Revised Cardiac Risk Index (RCRI) 2, 3, 4, 5, 6
- American College of Surgeons National Surgical Quality Improvement Program (NSQIP) calculator 4, 5, 6
- Myocardial Infarction or Cardiac Arrest index 4, 5
- NSQIP surgical risk calculator 5
Characteristics of Perioperative Risk Assessment Tools
Some key characteristics of these tools include:
- The RCRI is a useful tool in pre-operative risk stratification, but it may need to be updated to improve its predictive accuracy 2
- The RCRI discriminated moderately well between patients at low versus high risk for cardiac events after mixed noncardiac surgery, but it did not perform well at predicting cardiac events after vascular noncardiac surgery or at predicting death 3
- All four risk calculators (RCRI, NSQIP, Myocardial Infarction or Cardiac Arrest, and NSQIP surgical risk calculator) performed well in the setting they were originally studied, but were less accurate when applied in a different manner 4
- Clinical scores and biomarkers are well-established tools for risk prediction, but their accuracy remains a controversial issue 5
Comparison of Perioperative Risk Assessment Tools
Comparing the performance of different risk calculators:
- The RCRI, NSQIP, and Myocardial Infarction or Cardiac Arrest calculators were compared in predicting postoperative cardiac complications, and all performed well in defining low-risk patients, but the Myocardial Infarction or Cardiac Arrest calculator may be the most reliable in selecting higher risk patients 4
- The American College of Surgeons NSQIP calculator and the RCRI are recommended by current guidelines for preoperative cardiac risk assessment 5, 6