What is considered a normal Revised Cardiac Risk Index (RCRI) score?

What is Considered a Normal RCRI Score?

An RCRI score of 0-1 is considered normal/low risk, with a predicted major adverse cardiac event (MACE) rate of less than 1% after noncardiac surgery. 1, 2

RCRI Score Classification

The Revised Cardiac Risk Index stratifies patients into distinct risk categories based on the number of risk factors present:

• RCRI 0-1 (Low Risk): Cardiac complication rates of 0.4-1.3%, representing normal/low-risk patients who can proceed directly to surgery without additional cardiac testing 3, 1, 4

• RCRI 2 (Moderate Risk): Cardiac complication rates of 4-7%, indicating elevated risk requiring functional capacity assessment 3, 4

• RCRI ≥3 (High Risk): Cardiac complication rates of 9-11%, representing high-risk patients requiring comprehensive cardiac evaluation 3, 4

The Six RCRI Risk Factors

Each of the following counts as one point toward the total score 2, 4:

• History of ischemic heart disease
• History of congestive heart failure
• History of cerebrovascular disease
• Preoperative insulin treatment for diabetes mellitus
• Preoperative serum creatinine >2.0 mg/dL (177 µmol/L)
• High-risk surgery (intraperitoneal, intrathoracic, or suprainguinal vascular procedures)

Clinical Implications of Normal RCRI

Patients with RCRI 0-1 can proceed directly to surgery without additional preoperative cardiac testing, as the risk of major cardiac complications is less than 1%. 1, 2 This low-risk designation means:

• No routine stress testing or advanced cardiac imaging is indicated 1
• Standard perioperative monitoring is appropriate 2
• A 12-lead ECG is reasonable only if the patient has established cardiovascular disease or symptoms 1

Important Caveats

Despite being classified as "normal," approximately 8-13% of patients with RCRI 0-1 may still experience myocardial injury after noncardiac surgery (MINS) when systematic troponin monitoring is performed. 5 This highlights that:

• The RCRI was originally designed to predict clinical cardiac complications (MI, cardiac arrest, cardiac death), not subclinical myocardial injury 5
• Thirty-five percent of all cardiac events occur in patients with no RCRI risk factors 5
• The RCRI has moderate discriminative ability (C-statistic 0.65-0.69) and should not be the sole determinant of perioperative management 5

The RCRI performs differently across surgical populations. 6 It was derived from a mixed surgical cohort and may underestimate risk in vascular surgery patients, where procedure-specific risk calculators like the Thoracic RCRI (ThRCRI) may be more appropriate 3

Perioperative Management for Normal RCRI

For patients with RCRI 0-1, the American Heart Association/American College of Cardiology recommends 1:

• Continue chronic beta blockers if already prescribed (Class I) 1
• Continue statins if currently taking them (Class I) 1
• Consider guideline-directed medical therapy for long-term cardiovascular risk reduction 1
• Biomarker assessment (BNP/NT-proBNP) may be reasonable for additional risk stratification (Class 2a) 1

The negative predictive value of RCRI 0-1 exceeds 98% across all age groups, making it highly reliable for ruling out high cardiac risk. 7