Is the patient's preoperative risk intermediate low or high?

Perioperative Risk Classification

Based on the ACC/AHA guidelines, the patient's preoperative risk is intermediate-low. 1, 2

Understanding Risk Stratification

• The American College of Cardiology/American Heart Association (ACC/AHA) guidelines classify perioperative cardiac risk based on both patient-specific factors and surgery-specific risk 1
• Patients with a Revised Cardiac Risk Index (RCRI) score of 0-1 are classified as low risk, with a predicted major adverse cardiovascular events (MACE) risk of <1% 3
• Patients with RCRI score of 2 are considered intermediate-low risk, while those with RCRI ≥3 are considered intermediate-high to high risk 2, 3

Surgery-Specific Risk Assessment

• Surgical procedures are categorized as low risk (<1% risk of MACE), intermediate risk (1-5% risk of MACE), or high risk (>5% risk of MACE) based on invasiveness and hemodynamic stress 1, 2
• High-risk procedures include major vascular surgeries and procedures with significant fluid shifts or blood loss 1
• Intermediate-risk procedures include intraperitoneal and intrathoracic surgery, carotid endarterectomy, head and neck surgery, orthopedic surgery, and prostate surgery 1
• Low-risk procedures include endoscopic procedures, superficial procedures, cataract surgery, breast surgery, and ambulatory surgery 1

Patient-Specific Risk Factors

• Clinical risk factors include history of ischemic heart disease, history of compensated or prior heart failure, history of cerebrovascular disease, diabetes mellitus, and renal insufficiency 1, 2
• The presence of more than one clinical risk factor classifies a patient as high cardiac risk according to ACC/AHA guidelines 1
• A single clinical risk factor generally places the patient in the intermediate-low risk category 1, 3
• Patients with no clinical risk factors are considered low risk 1, 3

Functional Capacity Considerations

• Functional capacity is a critical predictor of perioperative adverse cardiovascular events 2
• Poor functional capacity (inability to achieve 4 METs) indicates increased risk and may warrant additional evaluation 2, 3
• For patients with intermediate-low risk and good functional capacity, additional cardiac testing is generally not necessary 3

Management Implications Based on Risk

• For low-risk patients, proceed directly to surgery without additional cardiac testing 3
• For intermediate-low risk patients with a single clinical risk factor, the usefulness of beta blockers is uncertain 1
• For intermediate-high to high-risk patients (more than one clinical risk factor), beta blockers are recommended, particularly for those undergoing vascular surgery 1
• Preoperative intensive care monitoring is rarely required and should be restricted to highly selected unstable patients with multiple comorbidities 1

Common Pitfalls in Risk Assessment

• Risk scores may have poorer discrimination in patients undergoing vascular surgery 2
• Relying solely on age as a risk factor without considering other comorbidities can lead to inaccurate risk assessment 2, 4
• Patient awareness of their own comorbidities can be low, potentially affecting risk assessment if relying solely on patient self-reporting 5

Remember that this risk classification should guide perioperative management decisions, including the need for additional cardiac testing and perioperative medical therapy.