Age-Specific Performance of the Revised Cardiac Risk Index for Predicting Cardiovascular Risk in Elective NonCardiac Surgery | Journal Scan

Study Questions:

What is the performance of the revised cardiac risk index (RCRI) in predicting major adverse cardiovascular events overall and in different age groups among unselected patients undergoing elective, noncardiac surgery?


All individuals ≥25 years old, who underwent major elective noncardiac surgery in Denmark from January 2005 through November 2011, were followed for the 30-day risk of major adverse cardiovascular events (ischemic stroke, myocardial infarction, or cardiovascular death). Patients were limited to those undergoing surgery involving a single anatomic site. Comorbidities were identified using a national hospitalization registry and based on previous discharge diagnoses within 5 years. The RCRI assigns 1 point each for ischemic heart disease, history of cerebrovascular disease, history of congestive heart failure, preoperative use of insulin, elevated creatinine (defined as a diagnosis of renal disease or need for dialysis), and high-risk surgery (thoracic, intra-abdominal, or suprainguinal aortic surgery). Cumulative points were converted to RCRI classes (0 points = class I; 1 point = class II; 2 points = class III; ≥3 points = class IV).


In RCRI classes I, II, III, and IV, there were 742 of 357,396 (0.2%), 755 of 74,889 (1.0%), 521 of 11,921 (4%), and 257 of 3,146 (8%) major adverse cardiovascular events. Multivariable odds ratio estimates were as follows: ischemic heart disease 3.30 (95% confidence interval, 2.96-3.69), high-risk surgery 2.70 (2.46-2.96), congestive heart failure 2.65 (2.29-3.06), cerebrovascular disease 10.02 (9.08-11.05), insulin therapy 1.62 (1.37-1.93), and kidney disease 1.45 (1.33-1.59). Modeling RCRI classes as a continuous variable, the C statistic was highest among the age group 56-65 years (0.772), and lowest for those ages >85 years (0.683). Sensitivity of RCRI class >I (i.e., having ≥1 risk factor) for capturing major adverse cardiovascular events was 59%, 71%, 64%, 66%, and 67% in patients ages ≤55, 56-65, 66-75, 76-85, and >85 years, respectively; the negative predictive values were >98% across all age groups.


In a nationwide unselected cohort in Denmark, the performance of the RCRI was similar to that of the original cohort. Having ≥1 risk factor was of moderate sensitivity for predicting perioperative major adverse cardiac events, but of high negative predictive value for all ages.


The RCRI holds a central role in preoperative cardiac risk stratification among patients undergoing noncardiac surgery. Its performance in unselected populations and in different age groups had not been systematically investigated. This study, taking advantage of available data from tax-financed medical care in Denmark, validates moderate sensitivity and a high negative predictive value of the RCRI across age groups. The high negative predictive value across all ages supports use of the RCRI in identifying patients at low risk for major adverse cardiovascular events complicating noncardiac surgery.

Clinical Topics: Heart Failure and Cardiomyopathies, Atherosclerotic Disease (CAD/PAD), Acute Heart Failure

Keywords: Coronary Artery Disease, Creatinine, Heart Failure, Hospitalization, Kidney Diseases, Myocardial Infarction, Registries, Risk, Risk Factors

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