Is it appropriate to apply the Revised Cardiac Risk Index to procedures performed solely under local anesthesia?

RCRI Should Not Be Applied to Procedures Requiring Only Local Anesthesia

The Revised Cardiac Risk Index (RCRI) was specifically designed and validated for major noncardiac surgery requiring general or neuraxial anesthesia, not for procedures performed under local anesthesia alone. 1

Why RCRI Is Inappropriate for Local Anesthesia Procedures

Original Design and Validation Context

• The RCRI was derived and validated specifically for patients undergoing "nonurgent major noncardiac surgery" requiring general or regional anesthesia 1
• One of the six RCRI risk factors is explicitly "high-risk surgery," defined as suprainguinal vascular, intraperitoneal, or intrathoracic procedures—all requiring general or neuraxial anesthesia 1
• The original Lee validation cohort excluded minor procedures and those performed under local anesthesia alone 1

Surgical Risk Classification Framework

• Guidelines classify surgical procedures into three risk categories based on 30-day cardiac event rates: low-risk (<1%), intermediate-risk (1-5%), and high-risk (>5%) 1
• Procedures performed under local anesthesia alone are universally classified as low-risk surgery and do not require formal cardiac risk stratification with tools like RCRI 1
• Patients undergoing low-risk surgery should proceed directly to the operating room without additional cardiac evaluation, regardless of clinical risk factors 1

Clinical Algorithm for Local Anesthesia Procedures

When to Skip RCRI Entirely

• For any procedure that can be completed with local anesthesia alone (e.g., skin lesion excision, dental procedures, cataract surgery), proceed directly to surgery without RCRI calculation 1
• The physiologic stress of local anesthesia procedures is minimal and does not trigger the cardiac complications that RCRI was designed to predict 1

Important Caveats

• If a procedure initially planned under local anesthesia may require conversion to general or neuraxial anesthesia, then preoperative cardiac evaluation becomes relevant 1
• Emergency surgery increases cardiac risk regardless of anesthetic technique, but the focus should be on immediate perioperative optimization rather than formal risk scoring 2
• Patients with active cardiac conditions (unstable angina, decompensated heart failure, significant arrhythmias, severe valvular disease) require evaluation and treatment regardless of surgical or anesthetic type 1

What to Do Instead for Local Anesthesia Cases

Minimal Evaluation Approach

• A basic clinical assessment focusing on active cardiac conditions is sufficient 1
• Continue chronic cardiac medications (beta-blockers, statins, ACE inhibitors) through the perioperative period 3, 4
• No routine preoperative ECG, laboratory testing, or cardiac imaging is indicated for asymptomatic patients 1

Common Pitfall to Avoid

• Do not reflexively calculate RCRI scores for all surgical patients—first determine if the procedure truly requires it based on anesthetic technique and surgical stress 1
• Overuse of RCRI in low-risk settings leads to unnecessary testing, delays in care, and increased healthcare costs without improving outcomes 1