RCRI Class I Risk of Major Cardiovascular Complications
Patients with RCRI Class I (0 risk factors) have a 0.4-0.5% risk of major adverse cardiac events (MACE) after noncardiac surgery, while those with RCRI score of 1 have a 1.0-1.3% risk, both falling well below the 1% threshold that defines low perioperative cardiac risk. 1, 2
Risk Stratification by RCRI Class
The Revised Cardiac Risk Index stratifies patients into distinct risk categories based on the number of clinical risk factors present:
- RCRI Class I (0 risk factors): 0.4-0.5% risk of major cardiac complications 1, 3
- RCRI score of 1: 1.0-1.3% risk of major cardiac complications 1, 3
- Combined RCRI 0-1: Classified as low risk with <1% predicted MACE rate 1, 2
Contemporary Validation Data
Recent large-scale studies confirm these risk estimates remain accurate in modern surgical populations:
A prospective cohort of 35,815 patients demonstrated RCRI Class I patients had an 8.2% incidence of the composite outcome that included myocardial injury after noncardiac surgery (MINS), but only 1.6% risk when MINS was excluded (capturing only MI, cardiac arrest, and cardiac death) 4
A single-center prospective study of 9,519 patients found RCRI Class I patients had a 0.5% rate of major cardiac complications 3
The original RCRI validation showed 0.4% risk for patients with zero risk factors 5
Clinical Implications for RCRI Class I Patients
Patients with RCRI 0-1 can proceed directly to surgery without additional preoperative cardiac testing, as the risk of major cardiac complications is less than 1%. 1, 2
No Additional Testing Required
- No routine stress testing or advanced cardiac imaging is indicated for RCRI Class I patients 1
- Standard perioperative monitoring is appropriate 1
- A 12-lead ECG is reasonable only if the patient has established cardiovascular disease or symptoms (Class 2a recommendation) 2
Perioperative Medical Management
- Continue chronic beta blockers if already prescribed (Class I recommendation) 1, 2
- Continue statins if currently taking them (Class I recommendation) 1, 2
- Continuation of ACE inhibitors or ARBs is reasonable perioperatively (Class IIa recommendation) 2
- Consider guideline-directed medical therapy for long-term cardiovascular risk reduction 1, 2
Important Caveats
Despite the low overall risk, 35% of all cardiac complications occur in patients without any RCRI risk factors, highlighting that RCRI Class I does not eliminate risk entirely. 4
The sensitivity of RCRI for capturing major adverse cardiovascular events in patients aged ≤55 years is only 59%, though the negative predictive value exceeds 98% across all age groups 6
Emergency surgery increases cardiac risk regardless of RCRI score, and the focus should shift to immediate perioperative medical optimization rather than extensive testing 2
Biomarker assessment (BNP/NT-proBNP) may be reasonable for additional risk stratification in select cases (Class 2a recommendation) 1, 2