Revised cardiac risk index (RCRI or Goldman Index)
Six independent predictors of major cardiac complications
- High-risk type of surgery (examples include vascular surgery and any open intraperitoneal or intrathoracic procedures)
- History of ischemic heart disease (history of MI or a positive exercise test, current complaint of chest pain considered to be secondary to myocardial ischemia, use of nitrate therapy, or ECG with pathological Q waves; do not count prior coronary revascularization procedure unless one of the other criteria for ischemic heart disease is present)
- History of Heart Failure
- History of cerebrovascular disease (Stroke or TIA)
- Diabetes mellitus requiring treatment with insulin
- Preoperative serum creatinine >2.0 mg/dL (177 micromol/L)
Rate of cardiac death, nonfatal myocardial infarction, and nonfatal cardiac arrest according to the number of predictors
No risk factors – 0.4 percent (95% CI: 0.1-0.8)
One risk factor – 1.0 percent (95% CI: 0.5-1.4)
Two risk factors – 2.4 percent (95% CI: 1.3-3.5)
Three or more risk factors – 5.4 percent (95% CI: 2.8-7.9)
A score of Zero or one risk factors = Low risk
Two or more is high risk. Refer high-risk patients to a cardiologist before getting surgery (KA).
*** The RCRI is a simpler tool to use and has been widely used and validated over the past 15 years. Another tool to calculate risk major cardiac events is the American College of Surgeons’ National Surgical Quality Improvement Program risk (ACS-NSQIP). You can download the Excel Spreadsheet from here >>. Both of these tools are equally effective. The RCRI has been validated more. Experts recommend that doctors should become familiar with one model and use it regularly.
SUMMARY
All patients scheduled to undergo noncardiac surgery should have an assessment of the risk of a cardiovascular perioperative cardiac event (algorithm 1). (See ‘Our approach’ above.)
Identification of risk factors is derived from the history, physical examination, and type of proposed surgery. (See ‘Initial preoperative evaluation’ above.)
We use either the Revised (Lee) Cardiac Risk Index or the ACS-National Surgical Quality Improvement Program risk prediction rule to establish the patient’s risk. (See ‘Estimating perioperative risk’ above.)
We obtain an EKG in patients with cardiac disease in large part to have a baseline available should a postoperative test be abnormal. (See ‘Initial preoperative evaluation’ above.)
For patients with known or suspected heart disease (ie, cardiovascular disease, significant valvular heart disease, symptomatic arrhythmias), we only perform further cardiac evaluation (echocardiography, stress testing, or 24-hour ambulatory monitoring) if it is indicated in the absence of proposed surgery. (See ‘Further cardiac testing’ above.)
A detailed review can be found here: http://www.uptodate.com/contents/evaluation-of-cardiac-risk-prior-to-noncardiac-surgery
“This patient has a Revised Cardiac Risk Index (Goldman Index) score of 1, placing him in a low-risk group for perioperative cardiac complications. Low-risk patients who are able to walk for 2 blocks or climb a flight of stairs without stopping to rest (4 METS) do not need noninvasive cardiac testing. Patients in this risk group who are already on a P-blocker should continue it, but adding one preoperatively may increase risk. Stopping aspirin therapy in patients with coronary stents places them at risk for perioperative cardiac events. Surgical bleeding is somewhat increased in patients on aspirin, but differences in the severity of bleeding events and mortality in surgical patients on low-dose aspirin versus controls are minimal. Stopping clopidogrel in patients who have recently undergone coronary stent placement (6 weeks for bare-metal stents, 1 year for drug-eluting stents) markedly increases risk, but there is no need to start clopidogrel in other patients. Perioperative statin therapy should be continued for all patients undergoing surgery. For patients undergoing vascular therapy, statins have been associated with an improvement in postoperative cardiac outcomes.
Ref: Holt NF: Perioperative cardiac risk reduction. Am Fam Physician 2012;85(3):239-246. 2) Drugs for lipids. Treat Guidel Med Lett 2012;9(103):13-20.“