What are the preoperative management strategies for patients with a high Revised Cardiac Risk Index (RCRI) score undergoing non-cardiac surgery?

Preoperative Management Strategies for High RCRI Score Patients Undergoing Non-Cardiac Surgery

For patients with a high Revised Cardiac Risk Index (RCRI) score undergoing non-cardiac surgery, a comprehensive risk assessment and optimization protocol should be implemented, including cardiac biomarker testing, appropriate medication management, and consideration of delay for elective procedures.

Risk Assessment and Classification

RCRI Score Components

• High-risk surgery
• History of ischemic heart disease
• History of congestive heart failure
• History of cerebrovascular disease (stroke/TIA)
• Diabetes mellitus requiring insulin
• Serum creatinine >2 mg/dL

Risk Stratification

• Class I (0 factors): 1.7% event rate 1
• Class II (1 factor): 2.0% event rate 1
• Class III (2 factors): 6.7% event rate 1
• Class IV (≥3 factors): 7.7% event rate 1

Preoperative Testing for High RCRI Patients

1. Essential Laboratory Tests:

   • Full blood count and renal function 2
   • Coagulation profile (prothrombin time, platelet count) 2
   • Cardiac biomarkers:
     • Troponin preoperatively AND at 24 and 48h post-surgery 2
     • BNP/NT-proBNP for risk stratification 3

2. Cardiovascular Assessment:

   • 12-lead ECG (mandatory for intermediate/high-risk patients) 2, 3
   • Echocardiography for high-risk patients undergoing high-risk non-urgent surgery 2
   • Functional capacity evaluation using two-flight stairs test or Duke Activity Status Index (DASI) 2, 3
   • Consider stress testing or coronary CT angiography if poor functional capacity (<4 METs) 3, 4

Medication Management

Beta-Blockers

• Continue beta-blockers in patients already on chronic therapy 2
• For patients with ≥3 RCRI factors not already on beta-blockers, consider initiating therapy before surgery 2
• Begin beta-blockers >1 day before surgery to assess safety and tolerability 2
• NEVER start beta-blockers on the day of surgery (Class III: Harm) 2

Statins

• Continue statins in patients already taking them 2
• Consider initiating statins in patients undergoing vascular surgery 2
• May consider initiating statins in patients with clinical risk factors undergoing elevated-risk procedures 2

Antihypertensive Medications

• Continuation of ACE inhibitors or ARBs is reasonable perioperatively 2
• If held, restart ACE inhibitors/ARBs as soon as clinically feasible postoperatively 2

Antiplatelet Therapy

• For patients with coronary stents:
  • Continue dual antiplatelet therapy (DAPT) during urgent surgery within 4-6 weeks of stent placement 2
  • If P2Y12 inhibitors must be discontinued, continue aspirin and restart P2Y12 inhibitor as soon as possible after surgery 2
• For patients without stents, continuing aspirin may be reasonable when cardiac event risk outweighs bleeding risk 2

Medications to Avoid

• Alpha-2 agonists are not recommended for prevention of cardiac events 2
• Avoid initiating high-dose beta-blockers immediately before surgery 4

Timing of Surgery

For Patients with Recent Coronary Intervention

• Delay elective surgery after balloon angioplasty for at least 14 days 2
• Delay elective surgery after BMS implantation for at least 30 days 2
• Delay elective surgery after DES implantation:
  • Optimally for 365 days 2
  • May consider after 180 days if risk of further delay outweighs risk 2
  • NEVER perform elective surgery within 30 days of BMS or 12 months of DES if DAPT must be discontinued 2

For High-Risk Patients Without Recent Intervention

• Consider delaying elective procedures to optimize medical therapy
• For time-sensitive procedures, implement risk reduction strategies

Additional Risk Factors to Consider

• Age >70 years (consider frailty assessment using validated tool) 2, 3, 1
• Poor general medical condition 1
• Emergency surgery 1
• Left bundle branch block on ECG 1

Perioperative Monitoring

• Troponin monitoring at 24 and 48 hours post-surgery for high-risk patients undergoing high-risk procedures 2
• Close hemodynamic monitoring during surgery
• Vigilant postoperative care with attention to cardiovascular complications

Common Pitfalls and Caveats

1. Overestimation of functional capacity: Objective assessment is more reliable than patient self-report
2. Inappropriate beta-blocker initiation: Starting too close to surgery increases mortality and stroke risk
3. Premature discontinuation of chronic cardiac medications: Continue most cardiac medications through surgery
4. Underestimating bleeding risk with antiplatelet therapy: Balance thrombotic vs. hemorrhagic risk
5. Neglecting non-cardiac risk factors: Age >70, poor general condition, and emergency surgery independently increase risk

By following this structured approach to preoperative management for patients with high RCRI scores, clinicians can significantly reduce perioperative cardiovascular morbidity and mortality in this high-risk population.