Screening and diagnosis

Classification and risk stratification

Perioperative care

Quality improvement

Patient education

Nonpharmacologic interventions

Therapeutic procedures

Respiratory support

Follow-up and surveillance

Specific circumstances

Preventative measures

Medical management

Surgical interventions

Inpatient care

Diagnostic procedures

Diagnostic investigations

Insufficient evidence to make a recommendation.

Strongly favor this test or intervention.

The Revised Cardiac Risk Index (RCRI) calculator assesses perioperative cardiac risks by taking into account six specific risk factors associated with the patient. Each factor corresponds to a condition or characteristic, and if the patient exhibits that factor, it scores 1 point. The total score, ranging from 0 to 6, represents the overall cardiac risk.

The six risk factors analyzed are as follows:
1. High-risk surgery (intraperitoneal, intrathoracic, or suprainguinal vascular surgery)
2. History of ischemic heart disease (including myocardial infarction, positive exercise test, ECG with pathological Q waves, current ischemic chest pain, or use of nitrate)
3. History of congestive heart failure (with manifestations such as pulmonary edema, bilateral rales, S3 gallop, paroxysmal nocturnal dyspnea, or pulmonary vascular redistribution on chest X-ray)
4. History of cerebrovascular disease (transient ischemic attack or stroke)
5. Use of insulin for diabetes
6. Preoperative creatinine level above 2 mg/dL or 178 mcmol/L

A boolean input for each risk factor determines its presence, scoring 1 point if true and 0 if false. The sum of these points results in the total score.

Based on the computed score, the calculator provides an interpretation reflecting the patient's estimated risk of experiencing a major cardiac event (MI, cardiac arrest, or mortality) within 30 days post-surgery:

- Score of 0: Risk is 3.9%
- Score of 1: Risk is 6.0%
- Score of 2: Risk is 10.1%
- Score of 3 or more: Risk is 15.0%

The calculator simplifies the complex assessment of cardiac perioperative risks into a quantifiable measure, guiding healthcare providers in evaluating and mitigating potential cardiac complications in surgical patients. Here is the summary of how scores are interpreted in relation to risk percentages:

| Score | Risk Interpretation                                  |
|-------|------------------------------------------------------|
| 0     | Risk of 30-day MI, cardiac arrest, or mortality is 3.9% |
| 1     | Risk of 30-day MI, cardiac arrest, or mortality is 6.0% |
| 2     | Risk of 30-day MI, cardiac arrest, or mortality is 10.1% |
| 3 or more | Risk of 30-day MI, cardiac arrest, or mortality is 15.0% |

This structured approach helps balance the decision-making process by providing a clear estimate of cardiac risk based on specific, patient-related factors.

The Revised Cardiac Risk Index (RCRI) is a clinical calculator used to estimate the risk of cardiac complications during the perioperative period in patients undergoing non-cardiac surgery. It is particularly useful for stratifying patients into different risk categories based on six identified risk factors: high-risk surgery, history of ischemic heart disease, history of congestive heart failure, history of cerebrovascular disease, insulin therapy for diabetes, and preoperative serum creatinine >2.0 mg/dL. 

The RCRI is not applicable to patients undergoing cardiac surgery, as it was specifically designed for non-cardiac surgical procedures. It also may not be as accurate in populations not represented in the original study, such as those with less common comorbidities or undergoing less common surgical procedures.

Revised Cardiac Risk Index for perioperative risks (RCRI)

The Surgical Apgar Score calculator evaluates postoperative risk by utilizing three critical inputs related to the patient's intraoperative status: estimated blood loss, lowest mean arterial pressure, and lowest heart rate. Each of these parameters is assigned a score based on predefined scales, which collectively determine the overall Surgical Apgar Score. The patient's responses are mapped to numerical scores as follows:

1. Estimated blood loss:
   - "> 1,000 mL" = 0
   - "601-1,000 mL" = 1
   - "101-600 mL" = 2
   - "<= 100 mL" = 3

2. Lowest mean arterial pressure:
   - "< 40 mmHg" = 0
   - "40-54 mmHg" = 1
   - "55-69 mmHg" = 2
   - ">= 70 mmHg" = 3

3. Lowest heart rate:
   - "> 85 bpm" = 0
   - "76-85 bpm" = 1
   - "66-75 bpm" = 2
   - "56-65 bpm" = 3
   - "<= 55 bpm" = 4
   - "Pathologic bradyarrhythmia or asystole" = 0

The total Surgical Apgar Score is the sum of the scores from these three parameters, with a possible range from 0 to 10. This total score provides an interpretation regarding the patient's risk of mortality and major complications or death. Here are the interpretation criteria based on score:

- A score of 0 to 2 indicates a 14% risk of mortality and a 75% risk of major complications or death.
- A score of 3 to 4 indicates a 14% risk of mortality and a 56% risk of major complications or death.
- A score of 5 to 6 indicates a 4% risk of mortality and a 16% risk of major complications or death.
- A score of 7 to 8 indicates a 1% risk of mortality and a 6% risk of major complications or death.
- A score of 9 to 10 signifies a 0% risk of mortality and a 4% risk of major complications or death.

The calculator processes the inputs by assigning scores according to the tables above, summing the scores, and then using the total to provide an interpretation of the patient's postoperative risk. The output consists of the calculated score and its corresponding interpretation.

| Input Parameter               | Options                | Score |
|-------------------------------|------------------------|-------|
| Estimated blood loss          | > 1,000 mL             | 0     |
|                               | 601-1,000 mL           | 1     |
|                               | 101-600 mL             | 2     |
|                               | <= 100 mL              | 3     |
| Lowest mean arterial pressure | < 40 mmHg              | 0     |
|                               | 40-54 mmHg             | 1     |
|                               | 55-69 mmHg             | 2     |
|                               | >= 70 mmHg             | 3     |
| Lowest heart rate             | > 85 bpm               | 0     |
|                               | 76-85 bpm              | 1     |
|                               | 66-75 bpm              | 2     |
|                               | 56-65 bpm              | 3     |
|                               | <= 55 bpm              | 4     |
|                               | Pathologic bradyarrhythmia or asystole | 0 |

The Surgical Apgar Score (SAS) is a clinical calculator used to assess the risk of postoperative complications in patients undergoing surgery. It is applicable to a wide range of surgical patients, including those undergoing general, vascular, thoracic, and orthopedic surgeries. The SAS is based on three intraoperative parameters: lowest heart rate, lowest mean arterial pressure, and estimated blood loss. The score ranges from 0 to 10, with lower scores indicating a higher risk of postoperative complications such as major morbidity or mortality. The SAS is particularly useful in guiding postoperative management and informing discussions about prognosis with patients and their families. However, it may not be applicable to patients undergoing certain types of surgery, such as cardiac or neurosurgery, where these parameters may be intentionally manipulated as part of the surgical procedure.

Surgical Apgar Score for postoperative risk (SAS score)

The Preoperative Mortality Predictor (PMP) score assists in estimating the risk of mortality around the time of surgery based on a range of patient factors. Each contributing factor corresponds to specific patient health conditions or demographics, with responses scored on a predefined scale. By asking about the patient's medical status, functional capabilities, age, and other health considerations, the tool calculates a score indicating potential risk, where higher scores suggest a greater risk of mortality.

Here's how each factor is scored:

- Inpatient status: Yes = 6, No = 0
- Sepsis: Yes = 4, No = 0
- Poor functional status: Yes = 3, No = 0
- Disseminated cancer: Yes = 1, No = 0
- Age, years:
  - < 65 = 0
  - 65-69 = 0.5
  - 70-79 = 1
  - >= 80 = 2
- Cardiac comorbidity: Yes = 5, No = 0
- Pulmonary comorbidity: Yes = 3, No = 0
- Renal comorbidity: Yes = 1, No = 0
- Liver comorbidity: Yes = 1, No = 0
- Steroids for chronic condition: Yes = 1, No = 0
- Weight loss (>10% in the last 6 months): Yes = 1, No = 0
- Bleeding disorder: Yes = 1, No = 0
- Do-not-resuscitate status: Yes = 1, No = 0
- Obesity: Yes = 1, No = 0

The total score is computed by summing all the individual scores corresponding to the patient's conditions and choices. Once the total score is calculated, it is used to interpret the perioperative mortality risk as follows:

- A score of 5 or lower indicates a 0.1% risk of perioperative mortality.
- Scores between 6 and 10 suggest a 0.6% risk.
- Scores between 11 and 15 imply a 2.4% risk.
- Scores ranging from 16 to 20 reflect a 12.6% risk.
- Scores between 21 and 25 correspond to a 37.5% risk.
- Scores of 26 or more suggest a risk of 40.0%.

This interpretation assists healthcare providers and patients in understanding mortality risk associated with surgery, facilitating informed decision-making.

The Preoperative Mortality Predictor (PMP) score is a clinical calculator used to estimate the risk of mortality in patients undergoing non-cardiac surgery. It is particularly useful for clinicians when planning surgical interventions, as it helps to identify high-risk patients and guide preoperative decision-making. The PMP score takes into account several factors including age, functional status, and the presence of comorbidities such as heart failure, liver disease, and cancer. It does not apply to patients undergoing cardiac surgery, as the risk factors and outcomes for these patients are different. The PMP score should be used with caution in patients with conditions not included in the score, as it may underestimate their risk.

Preoperative Mortality Predictor score (PMP score)

Perioperative cardiac risk management for noncardiac surgery

Stress testing

As per ACC/ACS/AHA/…/SVM 2024 guidelines, 

Management of anticoagulants

Management of anticoagulants, heparins

Cardiac biomarkers

Patients with ventricular arrhythmias

Electrocardiogram

ECG, high-risk patients

Management of postoperative complications

Management of postoperative complications (arrhythmias)

Patients with valvular heart disease

Patients with valvular heart disease, aortic regurgitation

Postoperative cardiac monitoring

Postoperative cardiac monitoring, troponin

Hemoglobin levels

Patients with carotid artery disease

Patients with carotid artery disease, carotid revascularization

Patients with valvular heart disease, aortic stenosis

Management of postoperative complications (PE)

Patients with valvular heart disease, MR

Prophylactic statins

Patients with peripheral artery disease

Patients with PAD

Management of anticoagulants (VKAs, minor procedures)

General principles

Patients with heart failure

Patients with HF

Management of anticoagulants, DOACs

Management of beta-blockers

Patients with valvular heart disease, MS

Patients with coronary artery disease

Patients with coronary artery disease, coronary artery revascularization

Management of anticoagulants, VKAs, elective surgeries/procedures

Patients with cardiac implantable electronic devices

Bleeding control

Coronary angiography

Patients with acute coronary syndrome

Patients with ACS

Blood pressure control

BP control

Pain management

Thromboprophylaxis

Management of postoperative complications, myocardial injury/ischemia

Coronary computed tomography angiography

Coronary CTA

Management of antiplatelets

Echocardiography

Prophylactic aspirin

Patients with cardiomyopathy

Cardiac risk assessment

Postoperative cardiac monitoring (ECG)

Management of hypertension

Management of renin-angiotensin-aldosterone system inhibitors inhibitors

Management of RAAS inhibitors inhibitors

Prophylactic beta-blockers

Patients with carotid artery disease, preoperative evaluation

Postoperative cardiac monitoring (general principles)

Management of anticoagulants (general principles)

Patients with adult congenital heart disease

Patients with supraventricular arrhythmias

Management of sodium-glucose cotransporter-2 inhibitors

Management of SGLT-2 inhibitors

Pulmonary artery catheterization

Patients with pericardial diseases

Hemodynamic monitoring

Management of statins

Mechanical circulatory support

Smoking cessation

General counseling

Patients with stroke

Patients with iron deficiency anemia

Patients with valvular heart disease, general principles

History and physical examination

Patients with obesity

Body temperature control

Patients with patent foramen ovale

Updated 2024 AHA/ACC guidelines for perioperative cardiac risk management for noncardiac surgery


Perioperative cardiac risk management for noncardiac surgery

Guidelines

Key sources