What is the management approach for patients with low or intermediate risk based on Rcri (Revised Cardiac Risk Index) 1?

Management of RCRI 1 (Low to Intermediate Risk) Patients Undergoing Non-Cardiac Surgery

Patients with an RCRI score of 0-1 are classified as low risk (<1% risk of major adverse cardiac events) and can proceed directly to surgery without additional preoperative cardiac testing. 1, 2

Risk Classification and Direct Surgical Clearance

• RCRI scores of 0-1 represent low-risk patients with predicted major adverse cardiovascular event rates of less than 1%, allowing them to bypass additional cardiac evaluation and proceed directly to surgery 1, 2
• No routine stress testing, advanced cardiac imaging, or coronary angiography is indicated for this risk category 2
• Standard perioperative monitoring is appropriate without need for intensive cardiac surveillance 2

Preoperative Assessment Requirements

A resting 12-lead ECG is reasonable (Class IIa) only if the patient has established cardiovascular disease or active cardiac symptoms, but is not routinely required for asymptomatic low-risk patients 1

• Routine preoperative evaluation of left ventricular function is not recommended without specific indications such as dyspnea of unknown origin or worsening heart failure symptoms 1
• Biomarker assessment (BNP/NT-proBNP) may be reasonable for additional risk stratification (Class IIa recommendation), though not mandatory in this low-risk group 1, 2

Perioperative Medical Management

Medications to Continue (Class I Recommendations)

• Continue beta blockers in patients already taking them chronically for established indications 1, 2
• Continue statins in patients currently on statin therapy 1, 2
• Continuation of ACE inhibitors or ARBs is reasonable perioperatively (Class IIa) 1

Long-Term Cardiovascular Risk Reduction

• Consider initiating guideline-directed medical therapy (GDMT) for long-term cardiovascular risk reduction and disease management as applicable, even though immediate perioperative risk is low 1, 2

Special Considerations for Functional Capacity

For patients with poor or unknown functional capacity (Duke Activity Status Index <34, METs <4), consider whether further testing would impact decision-making or perioperative care, though this rarely changes management in RCRI 0-1 patients 1

• Patients with good functional capacity (≥4 METs) can proceed to surgery even without additional evaluation 1
• Exercise or pharmacological stress testing should only be performed if abnormal results would lead to coronary revascularization, medication changes, or surgical cancellation 1

Important Caveats and Pitfalls

Emergency Surgery Exception

• Emergency surgery increases cardiac risk regardless of RCRI score, and focus should shift to immediate perioperative medical optimization rather than extensive preoperative testing 1

Population-Specific Limitations

• The RCRI substantially underestimates cardiac risk in vascular surgery patients, particularly those undergoing lower extremity bypass, endovascular AAA repair, and open AAA repair 3
• For thoracic surgery patients, the Thoracic Revised Cardiac Risk Index (ThRCRI) may be more appropriate, though some studies question its accuracy 1, 4
• The RCRI performs best in middle-aged patients (56-65 years) with C-statistic of 0.772, and has lower discriminative ability in patients over 85 years (C-statistic 0.683) 5

Negative Predictive Value

• The negative predictive value of RCRI 0-1 exceeds 98% across all age groups, meaning it is highly reliable at identifying patients who will NOT have cardiac complications 5
• However, sensitivity for capturing major adverse cardiac events is only 59-71% depending on age group, meaning some events will occur even in low-risk patients 5