What risk assessment scores, such as Gupta (Perioperative Cardiac Risk Index) and RCRI (Revised Cardiac Risk Index), should be used for a preoperative workup to evaluate a patient's risk of perioperative cardiac complications?

Preoperative Risk Assessment: Using RCRI and Gupta Scores

Start with the Revised Cardiac Risk Index (RCRI)

The RCRI should be your initial risk stratification tool for all patients undergoing non-cardiac surgery, as it is the most widely validated and recommended score despite moderate discriminative ability. 1, 2, 3

RCRI Components (6 factors, 1 point each):

• History of ischemic heart disease 1
• History of heart failure 1
• History of cerebrovascular disease 1
• Preoperative insulin-dependent diabetes 1
• Chronic renal dysfunction (creatinine >2 mg/dL) 1, 4
• High-risk surgery (intraperitoneal, intrathoracic, suprainguinal vascular) 1

Risk Stratification by RCRI Score:

• RCRI 0-1: Low risk (<1% MACE) - Proceed directly to surgery without additional cardiac testing 1, 2, 3
• RCRI 2: Moderate risk - Assess functional capacity; consider additional testing only if poor/unknown capacity AND results would change management 2, 5
• RCRI ≥3: High risk - Implement comprehensive cardiac monitoring, assess functional capacity, consider pharmacological stress testing if it would alter management 5, 3

When to Use the Gupta (NSQIP MICA) Score

The Gupta perioperative myocardial infarction and cardiac arrest (MICA) risk calculator may provide superior predictive discrimination compared to RCRI, particularly in broader surgical populations. 1, 3

Key Advantages of Gupta Score:

• Uses 21 components from the American College of Surgeons NSQIP database 1
• Better discrimination for mortality (C-statistic 0.944) and morbidity (C-statistic 0.816) 4
• More comprehensive than RCRI for predicting specific outcomes 1

When Gupta is Preferred:

• When more granular risk prediction is needed beyond simple low/moderate/high categories 1
• For institutional quality improvement initiatives requiring precise risk adjustment 4
• When RCRI shows intermediate risk (score of 2) and you need better discrimination 3

Critical Limitations to Recognize

RCRI Performs Poorly in Certain Populations:

• Vascular surgery patients: RCRI has reduced discrimination (AUC 0.64) due to underestimation of MI risk 1, 6
• Thoracic surgery patients: Consider using Thoracic RCRI (ThRCRI) instead, though accuracy is debated 2, 5
• Predicting mortality: RCRI discriminates poorly for death (median AUC 0.62) compared to cardiac events 6

Both Scores Have Limited Perioperative Predictive Value:

• Neither RCRI nor modified versions reliably predict MACE in the immediate perioperative period 7
• Both are better at predicting 30-day complications and long-term cardiovascular events 7

Mandatory Complementary Assessment: Functional Capacity

Always combine risk scores with structured functional capacity assessment using the Duke Activity Status Index (DASI), as functional capacity is an independent predictor of perioperative risk. 1, 2, 3

DASI Assessment:

• ≥4 METs (DASI ≥34): Good functional capacity - can proceed to surgery even with elevated RCRI 1, 2
• <4 METs (DASI <34): Poor functional capacity - consider pharmacological stress testing if results would change management 1, 2, 5
• Key threshold question: Can the patient climb 2 flights of stairs? (>4 METs activity) 1, 8

Algorithmic Approach to Risk Assessment

Step 1: Calculate RCRI Score

• Assign 1 point for each of the 6 risk factors present 1

Step 2: Assess Functional Capacity

• Use DASI questionnaire or ask about stair climbing ability 1, 2

Step 3: Determine Testing Strategy

• RCRI 0-1 + any functional capacity: No additional testing, proceed to surgery 2
• RCRI 2 + good functional capacity (≥4 METs): No additional testing 2
• RCRI 2 + poor/unknown functional capacity (<4 METs): Consider stress testing only if results would change management 2
• RCRI ≥3 + poor/unknown functional capacity: Consider pharmacological stress testing if results would alter perioperative care 5

Step 4: Consider Biomarker Assessment

• BNP/NT-proBNP measurement is reasonable for additional risk stratification in elevated-risk patients (RCRI ≥2) 2, 5, 3

Common Pitfalls to Avoid

Do Not Over-Test Low-Risk Patients:

• Patients with RCRI 0-1 can proceed directly to surgery without ECG, stress testing, or echocardiography 2
• Additional testing in low-risk patients increases costs without improving outcomes 8

Do Not Order Tests That Won't Change Management:

• Stress testing should only be performed if abnormal results would lead to coronary revascularization, medication changes, or surgical cancellation 1, 2, 8
• Routine preoperative coronary angiography is not recommended 2, 5

Do Not Rely Solely on Risk Scores for Vascular Surgery:

• RCRI significantly underestimates cardiac risk in vascular surgery patients 1, 6
• Consider using Gupta score or additional risk stratification tools in this population 1, 3

Emergency Surgery Overrides Risk Scores:

• Emergency surgery increases cardiac risk regardless of RCRI score 5
• Focus on immediate perioperative medical optimization rather than extensive testing 5

Practical Implementation

For RCRI 0-1 (Low Risk):

• Obtain 12-lead ECG only if patient has established cardiovascular disease or symptoms 2
• Continue chronic beta-blockers and statins 2
• Proceed to surgery without delay 2

For RCRI 2 (Moderate Risk):

• Assess functional capacity with DASI 2
• If functional capacity ≥4 METs: proceed to surgery 2
• If functional capacity <4 METs: determine if stress testing would impact decision-making 2
• Consider BNP/NT-proBNP for additional stratification 2

For RCRI ≥3 (High Risk):

• Comprehensive cardiovascular examination including vital signs, carotid pulses, jugular venous pressure, lung auscultation 5
• 12-lead ECG 5
• Assess functional capacity 5
• Consider pharmacological stress testing if poor/unknown functional capacity and results would change management 5
• Implement comprehensive intraoperative cardiac monitoring 5
• Consider postoperative surveillance for myocardial injury after non-cardiac surgery (MINS) 5, 3