What are the recommendations for a patient with a Revised Cardiac Risk Index (RCRI) score of 1 undergoing non-cardiac surgery?

Management Recommendations for Patients with RCRI Score of 1 Undergoing Non-cardiac Surgery

For patients with a Revised Cardiac Risk Index (RCRI) score of 1 undergoing non-cardiac surgery, they are considered low risk (<1% risk of major adverse cardiovascular events) and can proceed to surgery without additional cardiac testing.

Understanding RCRI Risk Stratification

• The RCRI is a validated tool for predicting perioperative risk of major adverse cardiovascular events (MACE), including myocardial infarction, pulmonary edema, ventricular fibrillation, cardiac arrest, and complete heart block 1, 2
• According to the 2024 AHA/ACC guidelines, patients with RCRI score of 0-1 are classified as low risk, with a predicted MACE risk of <1% 1
• The actual observed rates of major cardiac complications with 0 and 1 risk factors are approximately 0.5% and 2.6%, respectively 3

Recommendations for RCRI Score of 1

• Patients can proceed directly to surgery without additional cardiac testing 1, 2
• Preoperative cardiac testing is not recommended for patients with low risk of perioperative MACE 1
• Consider guideline-directed medical therapy (GDMT) initiation for long-term cardiovascular risk reduction and disease management as applicable 1

Perioperative Management Considerations

• A 12-lead ECG is reasonable in patients with established cardiovascular disease or symptoms (Class 2a recommendation) 1
• Continue beta blockers in patients who are on beta blockers chronically (Class I recommendation) 1
• Continue statins in patients currently taking statins (Class I recommendation) 1
• Continuation of ACE inhibitors or ARBs is reasonable perioperatively (Class IIa recommendation) 1

Important Caveats and Pitfalls

• The RCRI may underestimate cardiac complications in certain populations:

  • The VISION study found that 8.2% of patients with RCRI class I (0 risk factors) and 15.4% of patients with RCRI class II (1 risk factor) experienced cardiac complications when including myocardial injury after noncardiac surgery (MINS) 4
  • The RCRI may underestimate risk particularly for patients undergoing vascular surgery procedures 5

• Emergency surgery significantly increases cardiac risk regardless of RCRI score 2

• Age is an important factor affecting RCRI performance:

  • The sensitivity of RCRI class >I (having ≥1 risk factor) for capturing MACE varies across age groups (59% for age ≤55,71% for age 56-65) 6
  • The negative predictive value remains high (>98%) across all age groups 6

Special Considerations

• For patients with RCRI score of 1 undergoing vascular surgery, consider that the RCRI may underestimate risk, and additional risk assessment may be warranted 5
• For patients with poor or unknown functional capacity (Duke Activity Status Index <34, METs <4), consider whether further testing would impact decision-making or perioperative care 1
• Biomarker assessment (BNP/NT-proBNP) may be reasonable for additional risk stratification (Class 2a recommendation) 1

By following these recommendations, clinicians can appropriately manage patients with RCRI score of 1 undergoing non-cardiac surgery while minimizing unnecessary testing and interventions.