How is the Mayo surgical risk score used to predict postoperative complications and guide preoperative management?

Mayo Surgical Risk Score for Predicting Postoperative Complications

The Mayo Surgical Risk Score is a validated risk prediction tool that effectively identifies patients at risk for major cardiovascular complications after surgery, helping guide preoperative management and inform shared decision-making regarding surgical risk. 1

Overview of the Mayo Surgical Risk Score

The Mayo Surgical Risk Score is one of several validated tools used to predict perioperative risk of major adverse cardiovascular events (MACE). According to the 2024 AHA/ACC guidelines, risk prediction tools help identify patients with elevated risk, defined as ≥1% risk of MACE 2.

Key Components and Application

The Mayo Surgical Risk Score incorporates eight clinical and angiographic variables to predict complications including:

• Death
• Q-wave myocardial infarction
• Emergent/urgent coronary artery bypass graft surgery
• Cerebrovascular accident

The score has demonstrated excellent discrimination with an area under the receiver operating curve of 0.76 when validated in external datasets 1.

Integration into Perioperative Risk Assessment

The 2024 AHA/ACC guidelines recommend a stepwise approach to perioperative risk assessment:

1. Calculate baseline risk using a validated tool (Mayo Surgical Risk Score, RCRI, or ACS NSQIP) 3
2. Identify risk modifiers that increase perioperative risk 3
3. Assess functional capacity using tools like the Duke Activity Status Index (DASI) 3
4. Determine need for further testing based on risk level 2

Risk Stratification Categories

The Mayo Surgical Risk Score helps categorize patients into risk levels:

• Low risk: <1% risk of MACE
• Elevated risk: ≥1% risk of MACE (includes intermediate and high risk) 2

Clinical Decision-Making Based on Risk Assessment

For Low-Risk Patients (Mayo Score indicating <1% MACE risk):

• Proceed to surgery without further cardiac testing 3
• No routine preoperative evaluation of left ventricular function needed 3

For Elevated-Risk Patients (Mayo Score indicating ≥1% MACE risk):

• Consider 12-lead ECG 3
• For poor functional capacity, consider biomarker risk assessment (BNP/NT-proBNP, troponin) 3
• Consider noninvasive stress testing or coronary CT angiography for abnormal biomarkers 3

Advantages of the Mayo Surgical Risk Score

The Mayo Surgical Risk Score has several advantages:

• Validated in multi-center external datasets 1
• Accurately predicts cardiovascular complications
• Provides objective data for shared decision-making
• Helps identify patients who might benefit from preoperative optimization

Limitations and Considerations

• No single risk calculator is universally superior; the 2024 AHA/ACC guidelines note that "data are lacking to support the use of one risk index over another" 2
• Risk scores should be used as part of an overall assessment rather than in isolation
• Risk scores estimate population-based outcomes and should be applied to individual patients as part of comprehensive evaluation 2

Practical Application

1. Calculate the Mayo Surgical Risk Score preoperatively
2. Use the score to guide discussions with patients about surgical risk
3. For elevated-risk patients, consider additional testing or optimization
4. Document discussions about risks and potential outcomes with patients and families 2
5. Consider multidisciplinary team involvement for high-risk patients 2

The Mayo Surgical Risk Score represents an important tool in the perioperative risk assessment armamentarium, allowing for improved prediction of complications and more informed decision-making between clinicians and patients.