What are the perioperative management recommendations for a patient with a Revised Cardiac Risk Index (RCRI) score of 2 undergoing surgery?

Perioperative Management for RCRI Score 2

Patients with RCRI score 2 should proceed to surgery after functional capacity assessment, with additional cardiac testing only if functional capacity is poor (<4 METs) or unknown AND results would change management; continue all chronic cardiovascular medications perioperatively. 1, 2

Risk Classification

• RCRI score 2 represents elevated/moderate risk with ≥1% predicted risk of major adverse cardiac events (MACE), requiring more careful perioperative planning than low-risk patients 1, 2
• This differs from RCRI 0-1 (low risk, <1% MACE) who proceed directly to surgery without additional testing 1, 2

Functional Capacity Assessment - The Critical Decision Point

Assess functional capacity using the Duke Activity Status Index (DASI) to determine need for further testing: 1, 2

• If excellent functional capacity (≥4 METs or DASI ≥34): Proceed directly to surgery without additional cardiac testing 1, 3
• If poor functional capacity (<4 METs or DASI <34) or unknown capacity: Consider pharmacological stress testing (dobutamine stress echo or myocardial perfusion imaging) ONLY if abnormal results would change management (e.g., lead to coronary revascularization, medication changes, or surgical cancellation) 1, 2

Preoperative Testing

Reasonable preoperative tests for RCRI 2 patients: 1

• 12-lead ECG: Reasonable for patients with known cardiovascular disease or symptoms 1
• Biomarker assessment (BNP/NT-proBNP): May be reasonable for additional risk stratification 1, 3
• Avoid routine coronary angiography - not recommended 1, 2

Perioperative Medication Management

Continue all chronic cardiovascular medications perioperatively: 2

Beta Blockers

• Continue in all patients already taking them chronically (Class I recommendation) 1, 2
• For patients NOT on beta blockers: May be reasonable to initiate before surgery, but start >1 day before surgery to assess safety and tolerability - never start on day of or day before surgery as this is harmful 1, 2
• Adjust postoperatively for hypotension, bradycardia, or bleeding as needed 1

Statins

• Continue in all patients currently taking statins (Class I recommendation) 1, 2

ACE Inhibitors/ARBs

• Continuation is reasonable perioperatively (Class IIa recommendation), though monitor for intraoperative hypotension 1, 2

Antihypertensive Medications

• Continue chronic antihypertensives to avoid rebound hypertension, particularly with beta blockers and clonidine 4
• Use intravenous medications if unable to take oral medications 4

Blood Pressure Management

Intraoperative targets: 4, 2

• Maintain mean arterial pressure (MAP) ≥60-65 mm Hg or systolic blood pressure (SBP) ≥90 mm Hg 4, 2
• Hypotension below these thresholds for approximately 15 minutes is associated with myocardial injury, acute kidney injury, and mortality 4

Preoperative hypertension considerations: 4

• Preoperative SBP >160 mm Hg is associated with increased cardiovascular complications specifically in patients with ≥1 RCRI component 4
• In absence of RCRI components, little evidence for increased risk at BP <180/110 mm Hg 4
• Refer to baseline ambulatory BP rather than single elevated reading on day of surgery (may represent white coat hypertension) 4

Postoperative Monitoring

Measure cardiac troponin at 48-72 hours after surgery in all patients with RCRI ≥2 2, 3

Special Population Considerations - Critical Caveats

Do NOT use standard RCRI for: 2, 3

• Vascular surgery patients: RCRI substantially underestimates risk; use Vascular Study Group Cardiac Risk Index (VSG-CRI) instead 2
• Thoracic surgery patients: Use Thoracic Revised Cardiac Risk Index (ThRCRI) instead 2, 3, 5

Emergency surgery: Increases cardiac risk regardless of RCRI score; focus on immediate perioperative medical optimization rather than extensive testing 2, 3

Key Pitfalls to Avoid

• Do not order stress testing unless abnormal results would change management 2
• Do not start beta blockers on day of or day before surgery 2
• Do not perform routine preoperative coronary angiography 1, 2
• Do not defer surgery solely based on elevated BP <180/110 mm Hg in patients without other RCRI components 2