Harvey's Garden

Preoperative management

2 min read

Risk stratification tools

Revised Cardiac Risk Index (RCRI)

  • Indication

    • Predicts risk of Major Adverse Cardiac Events (MACE) prior to noncardiac surgery.

  • Components (1 point each)

    1. High-Risk Surgery: Intraperitoneal, intrathoracic, or suprainguinal vascular surgery (e.g., AAA repair).
    2. Ischemic Heart Disease: Hx of MI, positive stress test, current chest pain, use of nitrates, or pathologic Q waves.
    3. History of CHF: Pulmonary edema, PND, bilateral rales, or S3 gallop.
    4. History of Cerebrovascular Disease: TIA or Stroke.
    5. Diabetes Mellitus requiring Insulin.
    6. Preoperative Serum Creatinine > 2.0 mg/dL.

  • Risk Stratification

    • 0 pts: Very Low (<1%)
    • 1 pt: Low (~1%)
    • 2 pts: Moderate (~7%)
    • ≥3 pts: High (>11%)

  • Functional Capacity: METs (Metabolic Equivalents)

    • Threshold for surgery without further workup is 4 METs.
    • 1 MET (Resting): Eating, dressing, using the toilet.
    • < 4 METs (Poor): Light housework, walking slowly on level ground. (Needs further workup if RCRI ≥ 1).
    • ≥ 4 METs (Good): Climbing 2 flights of stairs, walking 4 blocks, heavy housework. (Proceed to OR).
    • > 10 METs (Excellent): Strenuous sports (running, swimming).

  • Pre-Op Management Algorithm c

    • Emergent? → Proceed to OR.
    • Elective + METs ≥ 4 (can climb 2 flights of stairs)? → Proceed to OR.
    • Elective + METs < 4 + RCRI = 0? → Proceed to OR.
    • Elective + METs < 4 + RCRI ≥ 1? → Pharmacologic stress test (ONLY if results will change mgmt).

  • High-Yield Pearls

    • Meds: Continue chronic BBs and statins. Do NOT initiate BB on day of surgery (↑ stroke/hypotension risk).
    • Intervention: Routine prophylactic PCI/CABG is never the right answer (unless independently indicated for ACS).

Graph View