What Gives a Patient a Score of 0 in RCRI
A patient receives an RCRI score of 0 when they have none of the six independent cardiac risk factors: no history of ischemic heart disease, no history of congestive heart failure, no history of cerebrovascular disease, no preoperative insulin-dependent diabetes, no chronic renal dysfunction (serum creatinine >2 mg/dL), and they are not undergoing high-risk surgery. 1, 2
The Six RCRI Risk Factors
Each of the following counts as one point toward the total RCRI score 1, 3:
- History of ischemic heart disease (including prior myocardial infarction, positive stress test, current chest pain from coronary disease, use of nitrate therapy, or ECG with pathological Q waves) 1
- History of congestive heart failure (including pulmonary edema, bilateral rales, S3 gallop, paroxysmal nocturnal dyspnea, or chest X-ray showing pulmonary vascular redistribution) 1
- History of cerebrovascular disease (prior transient ischemic attack or stroke) 1, 3
- Preoperative insulin treatment for diabetes mellitus (not oral hypoglycemics alone) 1, 3
- Chronic renal dysfunction (preoperative serum creatinine >2.0 mg/dL or >177 µmol/L) 1, 4
- High-risk surgery (intraperitoneal, intrathoracic, or suprainguinal vascular procedures) 1, 5
Clinical Significance of RCRI Score 0
Patients with an RCRI score of 0 are classified as low risk with a predicted major adverse cardiac event (MACE) rate of less than 1% after noncardiac surgery 2, 3. This represents the lowest risk category, where the risk of major cardiac complications including myocardial infarction, pulmonary edema, ventricular fibrillation, primary cardiac arrest, complete heart block, and cardiac-related death is minimal 6, 5.
Management Implications for RCRI Score 0
Patients with RCRI score 0 can proceed directly to surgery without additional preoperative cardiac testing, as the American Heart Association/American College of Cardiology guidelines recommend 2, 3. The following management principles apply:
- No routine stress testing or advanced cardiac imaging is indicated for these low-risk patients 2
- Standard perioperative monitoring is appropriate without need for specialized cardiac surveillance 2
- Continue chronic beta blockers if already prescribed (Class I recommendation), but do not initiate new beta blocker therapy 2, 3
- Continue statins if currently taking them (Class I recommendation) 2, 3
- A 12-lead ECG may be reasonable if the patient has established cardiovascular disease or symptoms, but is not mandatory for asymptomatic patients 3
Important Clinical Caveats
While RCRI score 0 indicates low risk, certain factors can still increase perioperative cardiac risk regardless of the score 5, 7:
- Emergency surgery increases cardiac risk independent of RCRI score, and focus should shift to immediate perioperative medical optimization rather than extensive testing 1, 3
- Age >70 years, poor general medical condition, and left bundle branch block on ECG were significantly associated with perioperative events even in lower RCRI categories 5
- Biomarker assessment (BNP/NT-proBNP) may be reasonable for additional risk stratification even in low-risk patients (Class 2a recommendation) 2, 3
Special Population Considerations
For patients undergoing thoracic surgery specifically, the American College of Chest Physicians recommends using the Thoracic Revised Cardiac Risk Index (ThRCRI) instead of the standard RCRI, as it has been externally validated for lung resection cohorts and provides more accurate risk assessment in this population 6, 1.