Revised Cardiac Risk Index (RCRI) Calculator

How does this Revised Cardiac Risk Index (RCRI) calculator work?

This is a health tool that estimates how likely it is for a patient undergoing surgery to develop perioperative cardiac events. It is used by clinicians in assessing the benefits and the risks of surgery in each individual case over the other treatment options that might be available.

This Revised Cardiac Risk Index (RCRI) calculator observes and evaluates patient variables as the ones described, from the type of surgery performed to the comorbidities in the specific case.

■ High-Risk Surgery – the patient will undergo one of the following types of surgery, deemed high risk for perioperative cardiac complications:

-­ Intraperitoneal;

- Intrathoracic;

- Suprainguinal vascular.

■ History of ischemic heart disease – characterized by either history of positive test, diagnosed MI, current chest pain suspicion of myocardial ischemia, under nitrate therapy or evidence of pathological Q waves on electrocardiogram.

■ History of congestive heart failure – described as the presence of either of the following:

- Pulmonary edema, bilateral rales or S3 gallop;

- Paroxysmal nocturnal dyspnea;

- CXR showing pulmonary vascular redistribution.

■ History of cerebrovascular disease - Prior TIA or stroke.

■ Pre-operative insulin treatment.

■ Pre-operative creatinine more than 2 mg/dL.

Every criteria employed in the RCRI score has independent predictive value and the accuracy of the study has been validated several times. It was developed by Lee in 1999 as derived from the Goldman study on cardiac risk complications and is now part of the preoperative cardiac risk evaluation guideline from the American Heart Association and American College of Cardiology.

Compared to the original study, the revised version appears to be not only easier to administer but also more accurate in clinical practice.

Major cardiac events or complications as they are referred to in both risk studies include:

■ Myocardial infarction;

■ Pulmonary edema;

■ Ventricular fibrillation;

■ Primary cardiac arrest;

■ Complete heart block.

Score interpretation

Each of the six criteria in the form is being awarded 1 point in case it is present. It is considered that the patient risk of suffering perioperative complications increases with the number of variables positive. Therefore the result range is between 0 and 6.

These scores belong to 4 classes, class I with the least risk and up to class IV presenting the higher risk of post operative cardiac complications. The percentage risks associated with each score are detailed below:

■ 0 - Class I risk 0.4%;

■ 1 - Class II risk 0.9%;

■ 2 - Class III risk 6.6%;

■ 3 to 6 - Class IV risk 11%.

Perioperative cardiac risk in noncardiac surgery

The RCRI alongside with the National Surgical Quality Improvement Program (NSQIP) are surgery specific risk assessment addressing cardiac surgery complications to be used by cardiac surgeons but there are also evaluations for noncardiac surgery.

This is a common assessment that clinicians need to perform when establishing the management route in treating patients who are deemed likely to develop preoperative complications. Administering and interpreting the cardiac index allows the clinician to address the cardiac risk factors before surgery and even define alternative treatment routes if the risk (patient- and surgery-specific) is too high.

Myocardial infarction and heart failure are common causes of morbidity and mortality even within noncardiac surgery.

The areas a physician needs to explore don’t end with cardiac issues but also include coagulopathy, anemia, chronic lung disease, cerebrovascular disease, renal disease and diabetes.

References

1) Goldman L, Caldera DL, Nussbaum SR, Southwick FS, Krogstad D, Murray B, Burke DS, O'Malley TA, Goroll AH, Caplan CH, Nolan J, Carabello B, Slater EE. (1977) Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med; 297(16):845-50

2) Lee TH, Marcantonio ER, Mangione CM, Thomas EJ, Polanczyk CA, Cook EF, Sugarbaker DJ, Donaldson MC, Poss R, Ho KK, Ludwig LE, Pedan A, Goldman L. (1999) Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation; 100(10):1043-9.