What further workup is recommended to risk stratify a patient with a Revised Cardiac Risk Index (RCRI) score of 4, indicating a 15% risk, for intermediate risk surgery?

From the Guidelines

For a patient with a Revised Cardiac Risk Index (RCRI) score of 4, which indicates a 15% risk of major cardiac events, I recommend obtaining a transthoracic echocardiogram (TTE) and stress testing, preferably pharmacological such as dobutamine stress echo or nuclear perfusion imaging, prior to intermediate risk surgery. The TTE will assess left ventricular function, valvular abnormalities, and pulmonary pressures, while stress testing will evaluate for inducible ischemia 1. Consider cardiology consultation to interpret these results and optimize medical management. Ensure the patient is on appropriate medications including beta-blockers, statins, and aspirin if indicated, as the use of beta-blockers is reasonable for patients undergoing intermediate-risk surgery who are at high cardiac risk owing to coronary artery disease or the finding of cardiac ischemia on preoperative testing 1. Optimize control of any contributing conditions such as hypertension, diabetes, and heart failure. Perioperative monitoring should include continuous ECG, arterial line placement for hemodynamic monitoring, and possibly ICU admission postoperatively.

Some key points to consider in the management of this patient include:

• The importance of preoperative cardiovascular risk assessment, as patients with lung cancer are predisposed to atherosclerotic cardiovascular disease due to cigarette smoking 1
• The use of cardiac risk scores, such as the RCRI, as a screening tool to select patients needing specialized preoperative cardiologic testing before proceeding to their surgical procedure 1
• The potential benefits and risks of perioperative beta-blocker therapy, including the recommendation to continue beta-blockers in patients undergoing surgery who are receiving them for treatment of conditions with ACCF/AHA Class I guideline indications 1
• The role of cardiopulmonary exercise testing (CPET) in detecting both overt and occult exercise-induced myocardial ischemia, and in providing data on peak oxygen consumption, a parameter associated with postoperative outcome 1

Overall, a comprehensive approach to the management of this patient is necessary to reduce the risk of major cardiac events and optimize outcomes.

From the Research

Risk Stratification for Intermediate Risk Surgery

To further risk stratify a patient with an RCRI (Revised Cardiac Risk Index) score of 4, which corresponds to a 15% risk of cardiac complications, the following workup can be considered:

• Stress echocardiography, as recommended by the European Association of Cardiovascular Imaging of the ESC 2, can be used to assess cardiac function and risk stratify patients undergoing intermediate risk surgery.
• The ABCDE protocol, which includes assessment of regional wall motion abnormality, regional perfusion, diastolic function, left ventricular contractile and preload reserve, and coronary flow velocity reserve, can provide comprehensive risk stratification 2.
• Carotid imaging can also be used to detect pre-obstructive atherosclerosis and improve risk prediction, similar to coronary atherosclerosis 2.
• The use of artificial intelligence in echocardiographic image acquisition and analysis can make stress echo more operator-independent and objective, providing a convenient and sustainable choice for functional testing 2.

Additional Considerations

• The choice of further workup should be individualized based on the patient's specific clinical characteristics and the type of surgery planned.
• The results of the stress echocardiography and other tests should be used to guide perioperative management and optimize cardiac risk reduction strategies.