What is the recommended preoperative cardiac evaluation and management for a patient with an RCRI (Revised Cardiac Risk Index) score of 2, undergoing cranioplasty, with a history of neurological disorders or previous cranial surgeries?

Preoperative Cardiac Evaluation for RCRI Score 2 Undergoing Cranioplasty

For a patient with RCRI score of 2 undergoing cranioplasty, assess functional capacity first—if ≥4 METs, proceed directly to surgery; if <4 METs or unknown, consider pharmacological stress testing only if results would change management, otherwise proceed to surgery with optimized medical therapy. 1

Risk Classification

• An RCRI score of 2 places this patient in the moderate-risk category, with approximately 7% risk of major cardiac complications 2, 3
• Cranioplasty is classified as intermediate-risk surgery (not high-risk), which influences the decision pathway 2
• The combination of RCRI 2 with intermediate-risk surgery typically results in <1-2% risk of major adverse cardiac events (MACE) 1

Initial Evaluation Steps

• Obtain a resting 12-lead ECG, which is reasonable for patients with known cardiovascular disease or structural heart disease 1
• Document the specific RCRI risk factors present (from: ischemic heart disease, heart failure, cerebrovascular disease, insulin-dependent diabetes, chronic kidney disease with creatinine >2.0 mg/dL, or high-risk surgery) 2, 3
• Assess left ventricular function only if the patient has dyspnea of unknown origin or worsening heart failure symptoms—routine echocardiography is not recommended 1, 4

Functional Capacity Assessment (Critical Decision Point)

• Use the Duke Activity Status Index (DASI) to quantify functional capacity; a score ≥34 corresponds to ≥4 METs and indicates adequate functional capacity 5
• If functional capacity is ≥4 METs: proceed directly to surgery without further cardiac testing 1, 5
• If functional capacity is <4 METs or unknown: determine whether additional testing would change management 1

Additional Testing (Only If It Changes Management)

• Pharmacological stress testing (dobutamine stress echocardiography or myocardial perfusion imaging) is reasonable only if abnormal results would lead to coronary revascularization, medication changes, or surgical cancellation 1, 5
• Routine preoperative coronary angiography is not recommended 1, 4
• Consider preoperative BNP or NT-proBNP measurement for enhanced risk stratification, particularly if the patient is ≥65 years old or 45-64 years with significant cardiovascular disease 5, 4

Perioperative Medical Management

Beta-Blockers

• Continue beta-blockers if the patient is already taking them chronically for Class I guideline indications 1
• For patients not on beta-blockers, initiation may be reasonable if started >1 day before surgery to assess safety and tolerability, but avoid initiation within 24 hours of surgery 1, 4
• Monitor closely for hypotension, bradycardia, or bleeding postoperatively and adjust accordingly 1

Statins

• Continue statins in patients currently taking them 1
• Consider initiating statin therapy for long-term cardiovascular risk reduction 1

ACE Inhibitors/ARBs

• Withhold ACE inhibitors and ARBs starting 24 hours before surgery to reduce risk of intraoperative hypotension 4
• Continuation is otherwise reasonable perioperatively in stable patients 1

Antiplatelet Therapy

• Do not initiate aspirin for perioperative cardiac event prevention unless the patient has a recent coronary stent or will undergo carotid endarterectomy 4

Postoperative Monitoring

• Measure troponin daily for 48-72 hours postoperatively in patients with RCRI ≥2, especially if preoperative BNP/NT-proBNP was elevated 5, 4
• This monitoring strategy identifies myocardial injury after noncardiac surgery (MINS), which carries significant prognostic implications 4

Common Pitfalls to Avoid

• Do not order stress testing reflexively—it should only be performed if results would alter management decisions 1, 5
• Do not delay surgery for extensive cardiac workup in patients with good functional capacity, as this increases risk without benefit 1
• Avoid starting beta-blockers within 24 hours of surgery, as this increases stroke and mortality risk 4
• Do not perform routine preoperative echocardiography without specific clinical indications like unexplained dyspnea or worsening heart failure 1, 4

Special Considerations for Cranioplasty

• Neurological history and previous cranial surgeries do not independently modify cardiac risk assessment algorithms 2
• The intermediate-risk classification of cranioplasty (not high-risk like intrathoracic or major vascular surgery) means many patients with RCRI 2 can proceed safely without extensive testing 2, 1
• Emergency surgery would necessitate proceeding with available optimization rather than extensive preoperative testing 5