What is better for preoperative evaluation, RCRI (Revised Cardiac Risk Index) or Aubhas2?

RCRI vs. AUBHAS2 for Preoperative Cardiac Risk Evaluation

The Revised Cardiac Risk Index (RCRI) is superior to AUBHAS2 for preoperative cardiac risk evaluation due to its extensive validation, widespread clinical adoption, and recommendation in the 2024 AHA/ACC guidelines for perioperative cardiovascular management. 1

Comparison of Risk Assessment Tools

Revised Cardiac Risk Index (RCRI)

• RCRI is a simple, validated, and commonly used tool to assess perioperative risk of major cardiac complications, with 6 predictors of risk (1 point assigned for each criterion) 1
• The RCRI has been extensively studied across multiple surgical populations and has become one of the most widely used risk indices in clinical practice 1
• RCRI risk factors include: ischemic heart disease, congestive heart failure, cerebrovascular disease, high-risk surgery, preoperative insulin treatment for diabetes mellitus, and preoperative creatinine >2 mg/dL 1
• Risk stratification with RCRI shows increasing risk with more factors: 0 factors (0.4%), 1 factor (1.1%), 2 factors (4.6%), and ≥3 factors (9.7%) for major cardiac complications 1

AUBHAS2 Risk Index

• The American University of Beirut (AUB) HAS2 cardiovascular risk index is a newer tool that stratifies patients into low (score 0-1), intermediate (score 2-3), and high risk (score >3) based on 6 data elements 1
• While AUBHAS2 is easily calculated, it has less extensive validation compared to the RCRI 1
• AUBHAS2 is designed specifically to assess 30-day event risk in non-cardiac surgery patients 1

Strengths and Limitations of RCRI

Strengths

• The RCRI is endorsed by the American College of Cardiology and American Heart Association in their 2024 guidelines for perioperative cardiovascular management 1, 2
• It provides moderate discriminative ability for cardiac events in patients undergoing non-cardiac surgery 2, 3
• The RCRI has been recalibrated for specific surgical populations (e.g., thoracic surgery as ThRCRI) to improve its predictive accuracy in specialized settings 1

Limitations

• In a pooled analysis of 24 validation studies, the RCRI showed modest risk discrimination for cardiac events, with some discordance among risk-prediction tools in identifying low-risk patients 1
• The RCRI may underestimate risk in vascular surgery patients, leading to the development of specialized indices like the VSG-CRI for this population 4
• Recent studies suggest that the RCRI alone may not be sufficient to guide postoperative cardiac monitoring, as approximately 1 in 12 patients ≥45 years without RCRI risk factors still experience cardiac complications 5

Improvements and Modifications to RCRI

• Replacing serum creatinine with glomerular filtration rate (GFR <30 mL/min) may improve the predictive ability of the index 6
• Adding biomarkers such as NT-proBNP or troponin to the RCRI can significantly improve its predictive performance for major adverse cardiac events (MACE) 7
• The thoracic revised cardiac risk index (ThRCRI) is a recalibrated version specifically for lung resection patients, which shows better discrimination in this population 1

Clinical Application and Decision-Making

• For initial cardiac risk assessment, use the RCRI as a validated screening tool before proceeding to more specialized cardiac testing 2, 3
• For patients with RCRI ≥2, consider additional risk assessment, including functional capacity evaluation using tools like the Duke Activity Status Index (DASI) 1
• In vascular surgery patients, consider using the VSG-CRI which more accurately predicts in-hospital cardiac events than the standard RCRI 4
• For thoracic surgery patients, the ThRCRI is recommended as it has been specifically recalibrated for this population 1

Practical Approach to Preoperative Evaluation

1. Determine the urgency of non-cardiac surgery (emergent vs. elective) 1
2. Assess for active cardiac conditions that might warrant delay of surgery 1
3. Calculate the RCRI score to stratify cardiac risk 1, 2
4. For intermediate to high-risk patients (RCRI ≥2), consider additional functional capacity assessment using DASI 1
5. Consider specialized risk indices for specific surgical populations (ThRCRI for thoracic surgery, VSG-CRI for vascular surgery) 1, 4
6. For highest-risk patients, consider adding biomarkers (NT-proBNP, troponin) to improve risk prediction 7

The RCRI remains the most widely validated and recommended tool for preoperative cardiac risk assessment, with stronger evidence supporting its use compared to the AUBHAS2 index.