Summary
Usage The Revised Cardiac Risk Index (RCRI) for pre-operative risk allows the clinician in the inpatient or outpatient preoperative setting to risk-stratify patients before undergoing a procedure or surgery. However, the score is not as well validated in emergency surgery patients. RCRI can also be a tool to help patients understand their individual risk profile as a part of an informed consent conversation. When patients present with elevated risk (RCRI ≥ 1, age ≥ 65, or age 45-64 with significant cardiovascular disease), additional preoperative risk stratification is provided (e.g. serum NT-proBNP or BNP) along with post-op cardiac monitoring recommendations (e.g. EKG, troponins). The RCRI has been validated by multiple studies. A large 2010 systematic review found moderate discrimination in predicting major perioperative cardiac complications (Ford, 2010). According to Duceppe (2017), other perioperative cardiac risk scores, such as the Myocardial Infarction and Cardiac Arrest (MICA) Score and the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) Score, have only been retrospectively validates and likely underestimates the risk of myocardial ischemia.. Summary The Revised Cardiac Risk Index (RCRI) is intended for the following population undergoing elective non-cardiac surgery or urgent/semi-urgent (non-emergent) non-cardiac surgery:Patients ≥ 45 years orPatients 18-44 years old with significant cardiovascular disease* *Significant cardiac disease refers to a known history ofcoronary artery diseaseperipheral artery diseasecongestive heart failuresevere pulmonary hypertension (PHTN)severe obstructive intracardiac abnormality (e.g. severe aortic stenosis, severe mitral stenosis or severe hypertrophic obstructive cardiomyopathy) Risk FactorDescriptionPointsElevated-risk surgery*Examples: intraperitoneal, intrathoracic, suprainguinal, carotid, head and neck, orthopedic, prostate, vascular (aortic and major vascular) 1History of ischemic heart diseaseHistory of myocardial infarction (MI); history of positive exercise test; current chest pain considered due to myocardial ischemia; use of nitrate therapy or ECG with pathological Q waves 1History of congestive heart failurePulmonary edema, bilateral rales or S3 gallop; paroxysmal nocturnal dyspnea; chest X-ray (CXR) showing pulmonary vascular redistribution 1History of cerebral vascular diseasePrior transient ischemic attack (TIA) or stroke 1Pre-operative treatment with insulin 1Pre-operative creatinine > 2 mg/dL or 176.8 µmol/L 1 *See 2014 ACC/AHA Guidelines RCRI ScoreRisk of major cardiac event (95% CI)*03.9% (2.8-5.4%)16.0% (4.9-7.4%)210.1% (8.1-12.6%)≥ 3 15% (11.1-20.0%) *Defined as death, myocardial infarction, or cardiac arrest at 30 days after noncardiac surgery (Duceppe, 2017). Management ConsiderationsOne or more of the following criteria have been met:RCRI score ≥ 1Age ≥ 65Age 45-64 with significant cardiac disease According to the 2016 CCS Perioperative Guidelines:Measure the patient's NT-ProBNP or BNP (if available)If NT-ProBNP is ≥ 300 ng/L or BNP ≥ 92 ng/L, then order an EKG in the PACU and troponins to be measured daily for 48-72 hours If NT-ProBNP is < 300 ng/L or BNP < 92 ng/L (after risk stratification), then no routine postoperative cardiac monitoring is warranted.If these assays are not available, then all patients requiremonitoring with an EKG in the PACU andtroponins to be measured daily for 48-72 hours.