What peri‑operative cardiovascular risk score should be used for a patient undergoing non‑cardiac surgery and how should management be guided by that score?

Perioperative Cardiovascular Risk Assessment for Non-Cardiac Surgery

Use the Revised Cardiac Risk Index (RCRI) as your primary risk stratification tool, calculating one point for each of six predictors: ischemic heart disease, heart failure, cerebrovascular disease, insulin-dependent diabetes, chronic kidney disease (creatinine >2 mg/dL), and high-risk surgery. 1, 2

RCRI Risk Stratification and Management Algorithm

RCRI Score 0-1 (Low Risk: <1% MACE)

• Proceed directly to surgery without additional cardiac testing 1, 2, 3
• Continue chronic beta-blockers and statins if already prescribed 3
• No stress testing or coronary angiography indicated 1, 3
• Event rate: 0.4-0.5% for RCRI 0, and 0.9-1.3% for RCRI 1 2, 4

RCRI Score 2 (Moderate Risk: 4-7% MACE)

• Assess functional capacity using the Duke Activity Status Index (DASI) 1, 2
• If functional capacity ≥4 METs (can climb 2 flights of stairs): proceed to surgery without further testing 1, 2
• If functional capacity <4 METs or unknown: consider pharmacological stress testing only if results would change management (e.g., lead to revascularization, medication changes, or surgical cancellation) 1, 2
• Event rate: 4-7% 2, 4

RCRI Score ≥3 (High Risk: 9-11% MACE)

• Implement comprehensive cardiac monitoring perioperatively 2
• Assess functional capacity with DASI 1, 2
• Consider stress testing only if poor functional capacity (<4 METs) and results would alter management 1, 2
• Consider postoperative troponin surveillance for myocardial injury after non-cardiac surgery (MINS) 2
• Event rate: 9-11% for RCRI ≥3, up to 14.4% in some cohorts 2, 5

Enhancing RCRI Predictive Power

Functional Capacity Assessment (Class IIa)

• Use the Duke Activity Status Index (DASI) for patients with RCRI ≥1 undergoing elevated-risk surgery 1, 2
• DASI scores ≤34 indicate increased odds of 30-day death or MI 2, 6
• The 12-item DASI questionnaire assigns weighted points (range 0-58.2) based on ability to perform activities from self-care (2.75 points) to strenuous sports (7.5 points) 1
• Functional capacity <4 METs confers 1.63 times higher rate of death, MI, acute heart failure, or life-threatening arrhythmias 6

Biomarker Enhancement (Class IIa)

• Measure preoperative BNP or NT-proBNP for patients with RCRI ≥2 to improve risk discrimination 2
• BNP improves discrimination with median Δc-statistic = 0.15 compared to RCRI alone 2
• NT-proBNP improves discrimination with median Δc-statistic = 0.08 2
• Abnormal thresholds: BNP >92 ng/L, NT-proBNP ≥300 ng/L 2
• Combined BNP and troponin provide median Δc-statistic improvement of 0.12 6

Alternative Risk Calculators

ACS NSQIP MICA Calculator

• Consider the NSQIP Myocardial Infarction and Cardiac Arrest (MICA) calculator for vascular surgery patients or when RCRI may be insufficient 2, 6
• Uses 21 variables from the American College of Surgeons NSQIP database 2, 6
• Demonstrates superior predictive discrimination with median Δc-statistic ≈0.11 higher than RCRI 2, 6
• Provides procedure-specific risk estimates using CPT codes rather than broad surgical categories 6

Thoracic Revised Cardiac Risk Index (ThRCRI)

• Use ThRCRI instead of standard RCRI for thoracic surgery patients 6
• Incorporates weighted factors including ischemic heart disease, cerebrovascular disease, serum creatinine, and pneumonectomy 6

What NOT to Do (Class III: No Benefit)

• Do not perform routine preoperative coronary angiography—it does not improve perioperative outcomes 1, 2, 7
• Do not initiate high-dose beta-blockers (e.g., metoprolol 100 mg) 2-4 hours before surgery—associated with increased stroke (1.0% vs 0.5%, P=0.005) and mortality (3.1% vs 2.3%, P=0.03) 7
• Do not use routine low-dose aspirin (100 mg/d) perioperatively—does not decrease cardiovascular events but increases surgical bleeding 7
• Do not perform routine coronary revascularization to reduce perioperative risk 7

Common Pitfalls and Caveats

Emergency Surgery

• Emergency surgery increases cardiac risk regardless of RCRI score 2, 3
• Focus on immediate perioperative medical optimization rather than extensive testing 6

RCRI Limitations

• RCRI has only modest discriminative ability (AUC ~0.79) 6, 7
• Performs poorly in vascular surgery populations—consider NSQIP MICA instead 2, 6
• Some original RCRI variables (insulin-dependent diabetes, creatinine >2 mg/dL) may not independently improve prediction 5
• Glomerular filtration rate <30 mL/min may be a better predictor than creatinine >176.8 mmol/L 5

High-Risk Populations

• Adults ≥75 years have greater risk of perioperative MI and MACE (9.5% vs 4.8% for younger adults, P<0.001) 7
• Patients with coronary stents have elevated risk (8.9% vs 1.5% without stents, P<0.001) 7
• History of ischemic heart disease is the strongest independent predictor of perioperative events among RCRI variables 8

Perioperative Medical Management

• Continue chronic beta-blockers in patients already taking them (Class I) 3
• Continue statins in patients currently taking them—associated with fewer postoperative cardiovascular complications (1.8% vs 2.3% mortality without statins, P<0.001) 7
• Consider statins preoperatively for patients with atherosclerotic cardiovascular disease undergoing vascular surgery 7
• Continuation of ACE inhibitors or ARBs is reasonable perioperatively (Class IIa) 3