From the Guidelines
The patient can proceed with cataract surgery without additional cardiac testing. Despite having a Revised Cardiac Risk Index (RCRI) score of 2, which typically indicates intermediate risk for perioperative cardiac complications, several factors mitigate this risk. The patient is currently asymptomatic, demonstrates good functional capacity, and is clinically stable. Additionally, cataract surgery is classified as a low-risk procedure with minimal hemodynamic stress, as noted in the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery 1. This guideline states that for patients with a low risk of perioperative major adverse cardiac events (MACE), further testing is not recommended, and cataract surgery is specifically mentioned as an example of a low-risk operation. Standard monitoring during the procedure is sufficient, and routine preoperative medications should be continued as per the anesthesiologist's guidance, with particular attention to antiplatelet or anticoagulant medications which may require specific perioperative management. The patient's regular cardiac medications should be continued through the perioperative period, especially beta-blockers and statins if prescribed. Key considerations in the perioperative period include:
- Continuing regular cardiac medications to maintain stability
- Managing antiplatelet and anticoagulant medications according to established protocols
- Monitoring for any signs of cardiac complications during and after surgery
- Ensuring good communication between the surgical team, anesthesiologist, and cardiologist regarding the patient's risk factors and management plan.
From the Research
Preoperative Recommendations
The patient has a Revised Cardiac Risk Index (RCRI) score of 2, but is asymptomatic and has good functional capacity. The patient is about to undergo cataract surgery, which is considered low risk.
- The RCRI score is used to predict the risk of cardiac complications in non-cardiac surgery patients 2.
- A study found that the RCRI score had a high negative predictive value in identifying patients at low risk for perioperative adverse cardiovascular events in non-cardiac surgery 2.
- However, the accuracy of the RCRI score in predicting cardiac complications is suboptimal in many clinical settings 2.
- Another study found that the RCRI score was useful in evaluating perioperative cardiac morbidity in kidney transplant recipients, with a receiver operating characteristic area of 0.77 3.
- The patient's asymptomatic status and good functional capacity are also important factors to consider when assessing their preoperative risk.
Risk Assessment
- The RCRI score takes into account five independent clinical determinants: history of ischemic heart disease, history of cardiovascular disease, heart failure, insulin-dependent diabetes mellitus, and chronic renal failure 2.
- The patient's RCRI score of 2 indicates that they have at least one of these clinical determinants, but the specific factors are not specified.
- A study comparing the RCRI score to the American Society of Anaesthesiologists physical status classification found that both tools were equally effective in predicting cardiac and pulmonary complications among patients undergoing non-cardiothoracic surgery 4.
Management
- Given the patient's low-risk surgery and stable condition, it is likely that no additional preoperative testing or interventions are necessary.
- However, the patient's RCRI score of 2 should be taken into account when developing their perioperative care plan.
- The anesthesiologist and surgical team should be aware of the patient's RCRI score and take steps to minimize the risk of cardiac complications during surgery, such as monitoring their cardiac function and blood pressure closely 5, 6.