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INTRODUCTION

Since Goldman's original cardiac risk index in 1977,1 multiple cardiac risk indices and calculators have been published to facilitate risk stratification for perioperative cardiac complications. The three most widely used and recommended by the ACC/AHA guidelines2 are the Lee Revised Cardiac Risk Index (RCRI),3 and the calculators derived from the NSQIP database – Gupta MI or Cardiac Arrest (MICA) calculator4 and the ACS5 Surgical Risk Calculator (ACS-SRC) (Table 9-1). However, before using any calculator, it is important to understand the setting in which it was derived, the population studied, types of surgery included, definitions of risk factors, and outcomes studied including the timeframe; otherwise, there is potential for misuse and incorrect risk stratification. These calculators should be used in the ACC/AHA algorithm to determine if the patient is at low (<1%) or elevated (≥1%) chance of having a major adverse cardiac outcome (MACE). (See details in Chapter 10 on CAD.)

TABLE 9-1Characteristics of Three Major Risk Calculators

ACC/AHA RECOMMENDED RISK CALCULATORS

Revised Cardiac Risk Index (RCRI)3

Lee and colleagues prospectively evaluated 4315 patients aged 50 years and older undergoing elective noncardiac, non-neurologic surgery with an expected hospital length of stay of at least 2 days. They developed a cardiac risk index composed of six variables, each given equal weighting: high-risk type of surgery (intrathoracic, intraabdominal, suprainguinal vascular), ischemic heart disease (not revascularized), history of congestive heart failure, history of cerebrovascular disease, insulin therapy for diabetes, and serum creatinine > 2.0 mg/dL. The frequency of major cardiac complications (MI, pulmonary edema, ventricular fibrillation or primary cardiac arrest, or complete heart block) during hospitalization increased with the number of risk factors present in both the derivation and validation patient cohorts (0.4–1.3% with 0–1 factors, 4–7% with 2 factors, and 9–11% with 3 or more factors).* Risk was underestimated for patients undergoing abdominal aortic aneurysm.

Myocardial Infarction or Cardiac Arrest (MICA) Calculator4

Using historical information from ...

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