Preoperative Cardiac Evaluation and Management for Patients with RCRI Score of 2
For patients with a Revised Cardiac Risk Index (RCRI) score of 2, additional cardiac evaluation is recommended based on functional capacity assessment, with pharmacological stress testing if functional capacity is poor or unknown and would impact management decisions. 1
Risk Assessment and Classification
- An RCRI score of 2 indicates elevated cardiac risk with ≥1% risk of major adverse cardiac events (MACE) during non-cardiac surgery 2
- The RCRI predicts risk of major cardiac complications including myocardial infarction, pulmonary edema, ventricular fibrillation, cardiac arrest, and complete heart block 2
- Patients with RCRI score of 2 have approximately 6.7% risk of cardiac complications, which is substantially higher than the 2.6% risk for patients with RCRI score of 0 3
Initial Evaluation
- A preoperative resting 12-lead ECG is reasonable for patients with known coronary heart disease or other significant structural heart disease 1
- Assessment of left ventricular function is reasonable for patients with dyspnea of unknown origin or heart failure with worsening symptoms 1
- Routine preoperative evaluation of LV function is not recommended without specific indications 1
Functional Capacity Assessment
- For patients with RCRI score of 2 and excellent functional capacity (≥4 METs), proceed to surgery without further evaluation 1
- For patients with RCRI score of 2 and poor (<4 METs) or unknown functional capacity, determine if further testing would impact decision-making or perioperative care 1
- Exercise testing may be reasonable to assess functional capacity if it would change management 1
Additional Testing Considerations
- If functional capacity is poor or unknown, pharmacological stress testing (dobutamine stress echocardiogram or myocardial perfusion imaging) is reasonable if it will change management 1
- Biomarker assessment (BNP/NT-proBNP) may be reasonable for additional risk stratification 2, 4
- Routine preoperative coronary angiography is not recommended 1
Perioperative Medical Management
- Continue beta blockers in patients who are on beta blockers chronically for conditions with Class I guideline indications 1, 5
- In patients with RCRI score of 2 who are not on beta blockers, it may be reasonable to begin beta blockers before surgery, preferably more than 1 day before surgery to assess safety and tolerability 1, 5
- Beta blockers should not be started on the day of surgery due to increased risk of harm 5
- Continuation of ACE inhibitors or ARBs is reasonable perioperatively, but consider withholding them 24 hours before surgery 2, 4
- Continue statins in patients currently taking them 2
Special Considerations
- The Thoracic Revised Cardiac Risk Index (ThRCRI) may be more appropriate for patients undergoing thoracic surgery, though some studies question its accuracy 1, 6
- More recent studies suggest that using glomerular filtration rate (GFR) <30 mL/min instead of creatinine >2.0 mg/dL may improve risk prediction 7
- The Vascular Study Group of New England Cardiac Risk Index (VSG-CRI) may be more accurate than RCRI for vascular surgery patients 3
Post-Operative Monitoring
- Consider daily troponin monitoring for 48-72 hours after surgery in patients with RCRI score of 2 4
- Management of beta blockers after surgery should be guided by clinical circumstances, with attention to modifying or temporarily discontinuing them as needed for hypotension, bradycardia, or bleeding 1, 5
By following this structured approach to preoperative cardiac evaluation and management for patients with RCRI score of 2, clinicians can appropriately assess and mitigate perioperative cardiac risk while avoiding unnecessary testing.