Risk of MACE with RCRI Score of 1
A patient with an RCRI score of 1 has a low risk of major adverse cardiac events (MACE), with an estimated perioperative risk of less than 1%, and can proceed directly to surgery without additional cardiac testing. 1, 2
Risk Stratification
Patients with 0 or 1 RCRI predictor are classified as low risk with a predicted MACE rate below 1% after noncardiac surgery. 1
The RCRI stratifies patients based on six independent predictors: history of ischemic heart disease, congestive heart failure, cerebrovascular disease, preoperative insulin-dependent diabetes, chronic renal dysfunction (creatinine >2 mg/dL), and high-risk surgery (suprainguinal vascular, intraperitoneal, or intrathoracic procedures). 1
With RCRI 0-1, the cardiac complication rate ranges from 0.4% to 1.3%, representing the lowest risk category where routine preoperative cardiac evaluation is not indicated. 2, 3
Clinical Management Approach
For patients with RCRI score of 1:
No further cardiac testing is recommended before proceeding to surgery, as the risk threshold does not justify additional evaluation. 1
Proceed directly to surgery with standard perioperative monitoring and guideline-directed medical therapy as appropriate. 2, 3
A preoperative 12-lead ECG is reasonable (Class IIa) if the patient has known coronary heart disease, significant arrhythmia, peripheral arterial disease, cerebrovascular disease, or other structural heart disease—but not for low-risk surgery. 1
Perioperative Medical Management
Continue existing cardiovascular medications:
Beta blockers should be continued in patients already taking them chronically for Class I guideline indications. 2, 3
Statins should be continued in patients currently on statin therapy. 2, 3
ACE inhibitors or ARBs continuation is reasonable perioperatively (Class IIa recommendation). 2
Consider initiating guideline-directed medical therapy for long-term cardiovascular risk reduction as clinically appropriate. 2, 3
Important Caveats
Emergency surgery increases cardiac risk regardless of RCRI score, and the focus should shift to immediate perioperative optimization rather than extensive preoperative testing. 4
Surgery type significantly influences actual risk: even with multiple risk factors, very low-risk procedures (e.g., cataract surgery, plastic surgery) maintain low MACE risk, while major vascular surgery with few risk factors may have elevated risk. 1
Biomarker assessment (BNP/NT-proBNP) may be reasonable for additional risk stratification (Class 2a), though not routinely required for RCRI score of 1. 2, 3
The RCRI has moderate discriminative ability and may perform poorly in specific populations such as vascular surgery patients or those on chronic dialysis, where alternative tools like the Gupta MICA calculator may provide superior prediction. 4, 5, 6
Recent research suggests RCRI may overestimate risk in certain populations, particularly in patients on chronic kidney replacement therapy where the expected-to-observed outcome ratio was 6.0 for RCRI score of 1. 6