What is the recommended management for patients with elevated Revised Cardiac Risk Index (RCRI) risk undergoing non-cardiac surgery?

Management of Patients with Elevated RCRI Risk Undergoing Non-Cardiac Surgery

For patients with elevated RCRI scores (≥2), proceed directly to surgery if functional capacity is good (≥4 METs), but consider pharmacological stress testing only if functional capacity is poor or unknown AND results would change management decisions. 1

Risk Stratification Based on RCRI Score

Low Risk (RCRI 0-1)

• Patients can proceed directly to surgery without additional cardiac testing, as predicted major adverse cardiovascular events (MACE) risk is <1% 2
• No further preoperative cardiac evaluation is needed unless specific symptoms or clinical changes warrant assessment 1

Elevated Risk (RCRI ≥2)

• Management is determined primarily by functional capacity assessment, not by RCRI score alone 1, 2
• The key decision point is whether the patient can achieve ≥4 METs of activity 2, 3

Functional Capacity-Based Algorithm for Elevated Risk Patients

Excellent Functional Capacity (>10 METs)

• Proceed directly to surgery without further testing 1
• This represents Class IIa recommendation with Level B evidence 1

Moderate to Good Functional Capacity (4-10 METs)

• It is reasonable to forgo further exercise testing and proceed to surgery 1
• This represents Class IIb recommendation with Level B evidence 1

Poor or Unknown Functional Capacity (<4 METs or unknown)

• Pharmacological stress testing (dobutamine stress echo or myocardial perfusion imaging) is reasonable ONLY if results will change management 1
• This represents Class IIa recommendation with Level B evidence 1
• Management changes include: coronary revascularization, medication adjustments, or surgical cancellation 3
• If testing won't alter the surgical plan, proceed without testing 1

Preoperative Testing Recommendations

12-Lead ECG

• Reasonable for patients with known coronary heart disease or significant structural heart disease (except low-risk surgery) 1, 2
• Not useful for asymptomatic patients undergoing low-risk procedures 1

Left Ventricular Function Assessment

• Reasonable for patients with dyspnea of unknown origin 1
• Reasonable for heart failure patients with worsening dyspnea or clinical status change 1
• Routine evaluation of LV function is NOT recommended without specific indications 1, 2

Stress Testing Contraindications

• Routine screening with noninvasive stress testing is NOT useful for low-risk noncardiac surgery 1
• Routine preoperative coronary angiography is NOT recommended 1

Coronary Revascularization Considerations

Routine coronary revascularization before noncardiac surgery exclusively to reduce perioperative cardiac events is NOT recommended 1

Limited Indications for Preoperative PCI:

• Left main disease when comorbidities preclude bypass surgery 1
• Unstable coronary artery disease requiring emergency/urgent revascularization 1
• ST-elevation MI or non-ST-elevation acute coronary syndrome benefiting from early invasive management 1

Timing Considerations:

• If drug-eluting stent placed, elective noncardiac surgery may be considered after 180 days 1
• For time-sensitive surgery, consider balloon angioplasty or bare-metal stent 1

Perioperative Medical Management

Beta-Blockers

• Continue in patients already on chronic beta-blocker therapy (Class I recommendation) 2, 4
• For RCRI ≥2 patients not on beta-blockers, it may be reasonable to begin before surgery, preferably >1 day before to assess tolerability 2
• Monitor for hypotension, bradycardia, or bleeding postoperatively 2

Statins

• Continue in patients currently taking statins (Class I recommendation) 2

ACE Inhibitors/ARBs

• Continuation is reasonable perioperatively (Class IIa recommendation) 2, 4
• In select patients with controlled blood pressure undergoing elevated-risk surgery, omission 24 hours before surgery may be beneficial to limit intraoperative hypotension (Class IIb recommendation) 4
• Restart as soon as clinically feasible postoperatively if held 4

Enhanced Risk Stratification Options

Biomarker Assessment

• NT-proBNP and/or troponin measurement preoperatively may be reasonable for additional risk stratification in patients with RCRI ≥2 (Class IIa recommendation) 2, 3
• Combination improves discrimination with median delta c-statistic of 0.12 3

Alternative Risk Calculators

• Consider the Gupta MICA calculator for superior predictive discrimination compared to RCRI, particularly in broader surgical populations 3
• For thoracic surgery specifically, consider the Thoracic RCRI (ThRCRI) instead of standard RCRI 2, 3

Common Pitfalls and Caveats

RCRI Limitations

• RCRI substantially underestimates cardiac risk in vascular surgery patients, with actual event rates 1.7- to 7.4-fold higher than predicted 5
• 35% of cardiac complications occur in patients with RCRI score of 0, highlighting the need for systematic troponin monitoring regardless of score 6
• RCRI has only moderate discriminative ability (C-statistic 0.65-0.69) 6

Testing Pitfalls

• Do not order stress testing unless abnormal results would lead to specific management changes (revascularization, medication changes, or surgical cancellation) 3
• Emergency surgery increases cardiac risk regardless of RCRI score; focus on immediate perioperative optimization rather than extensive testing 3

Medication Management Pitfalls

• Abrupt discontinuation of ACE inhibitors/ARBs may cause rebound hypertension 4
• Continuing ACE inhibitors/ARBs increases intraoperative hypotension risk requiring more vasopressor support 4
• Ensure clear communication about which medications to take or withhold on surgery morning 4