Preoperative Cardiac Risk Calculators
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1 The Fort Lauderdale, Florida Preoperative Cardiac Risk Calculators Steven L. Cohn, MD, FACP, SFHM Professor Emeritus Director - Medical Consultation Service Jackson Memorial Hospital University of Miami Miller School of Medicine
2 The Fort Lauderdale, Florida 2018 Perioperative Medicine Summit March 7-10, 2018 Steven L. Cohn, MD, FACP, SFHM Preoperative Cardiac Risk Calculators Dr. Cohn has disclosed that there is no actual or potential conflict of interest in regards to this presentation. The planners, editors, faculty and reviewers of this activity have no relevant financial relationships to disclose. This presentation was created without any commercial support.
3 The Fort Lauderdale, Florida Learning Objectives At the conclusion of this lecture, participants will be able to: Review the history of cardiac risk indices/calculators Define risk factors and outcomes of major risk calculators Discuss pros and cons of each
4 ARS Question ACC Guidelines & Risk Calculators A 70 y/o man is scheduled for partial thyroidectomy. PMH: HTN, DM, CKD, CVA, OA; no MI, HF; Meds: amlodipine, ACEI, insulin, ASA. No CP/SOB; exercise capacity 1 block due to knee pain. Exam WNL; Gluc 200, Creat 2.1; EKG NSR, LVH, LAHB What would you recommend preoperatively? A) Resting 2D Echo B) Dobutamine stress ECHO C) Adenosine nuclear stress imaging D) BNP or NT-proBNP E) No further testing The Fort Lauderdale, Florida
5 Risk Calculators Question RCRI - >10% (3 risk factors: DM, CKD, CVA) MICA 0.67% ACS NSQIP SRC 0.8% Don t use the RCRI for low risk or ambulatory procedures. The planned surgery should have an expected LOS >2 days. Otherwise you will grossly overestimate the risk. #Periop2018
6 Preoperative Cardiac Risk Indices (& Guidelines) ASA Detsky ACC Lee RCRI VSGNE ACS NSQIP CCS Goldman Larssen ACP ACC Gupta MICA R-RCRI VQI GS-CRI
7 Preoperative Cardiac Risk Indices & Calculators Older Newer GUIDELINES Goldman Original CRI Lee RCRI ACC/AHA Detsky Modified CRI VSGNE (vasc) ACP Larsen Gupta MICA ESC Cooperman (vasc) ACS Surg Risk Calculator CCS Eagle (vasc) L Italien (vasc) (Dripps ASA-PS) (Charlson comorbidity) (APACHE) #Periop2018 R-RCRI GS-CRI (geriatric) VQI (vasc) (CEA, open AAA, EVAR, supraing, infraing) (SAS) (POSSUM)
8 ACC/AHA Algorithm Step 3: If the patient has risk factors for stable CAD, then estimate the perioperative risk of MACE on the basis of the combined clinical/surgical risk. This estimate can use the American College of Surgeons NSQIP risk calculator ( or incorporate the RCRI with an estimation of surgical risk.
9 Characteristics of 3 Major Risk Calculators Methodology # of patients (derivation/validation) # of hospitals RCRI MICA ACS SRC Prospective ( ) 4,315 (2,893/1,422) 1 Historical (NSQIP) ( ) 468,795 (211,410/257,385) >200 Historical (NSQIP) ( ) 1,414, Age >50 >16 >16 Type of surgery Nonemergent Noncardiac LOS>2days 21 categories Excluded trauma and transplant pts # risk factors Outcomes MI, pulm edema, VF/cardiac arrest/chb MI, cardiac arrest Time frame In-hospital 30 days 30 days 1557 CPT codes MI, cardiac arrest, multiple noncardiac #Periop2018
10 Comparison of Risk Factors Revised Cardiac Risk Index (RCRI) High-risk surgery (3 categories) Ischemic heart disease Congestive heart failure Cerebrovascular disease Renal insufficiency (Cr>2mg/dl) Diabetes treated with insulin MI or Cardiac Arrest Calculator (MICA) Type of surgery (21 categories) ASA class Age Functional dependence Renal insufficiency (Cr>1.5mg/dl) ACS NSQIP Surgical Risk Calculator (ACS-SRC) Surgical procedure (CPT codes) Dyspnea Emergency? Previous cardiac event ASA class Smoker Age group (within past year) Functional dependence Congestive heart failure Severe COPD (<30 days) Ventilator dependent Acute renal failure Dialysis Disseminated cancer Diabetes on oral meds or Sepsis insulin (within 48 hrs) Hypertension requiring meds Wound class BMI class Steroid use (chronic) Sex Ascites (within 30 d)
11 Definitions of Complications MI Cardiac arrest VF Pulmonary edema Complete heart block #Periop2018 RCRI CK-MB>5% CK-MB>3% + ECG changes CXR reading + clinical setting MICA & ACS-SRC (NSQIP definitions) ECG changes: ST elev >1mm, >2 leads New LBBB New Q wave New elev in troponin>3x ULN in setting of ischemia Absence of card rhythm or presence of chaotic rhythm with LOC req BLS/ACLS (malign vent/supravent arrhythmias, PEA, asystole)
12 RCRI Risk Factor Definitions 1) High-risk surgical procedures Intraperitoneal Intrathoracic Suprainguinal vascular 2) Ischemic heart disease History of myocardial infarction History of a positive exercise test Current complaint of chest pain considered to be secondary to myocardial ischemia Use of nitrate therapy ECG with pathological Q waves (not revascularization only) 3) History of congestive heart failure History of CHF Pulmonary edema Paroxysmal nocturnal dyspnea Bilateral rales or S3 gallop CXR showing pulmonary vascular redistribution 4) History of cerebrovascular disease History of TIA or stroke 5) Insulin therapy for diabetes 6) Preoperative serum creatinine >2.0 mg/dl
13 Revised Cardiac Risk Index (RCRI) (Lee et al, Circulation 1999;100: ) 4315 pts, >50 y/o, major noncardiac surgery (LOS >2 days) 6 independent predictors: high-risk surgery (3 types), hx ischemic heart disease, CHF, CVA/TIA, DM Rx with insulin, preop creat >2.0 mg/dl # of risk factors % major cardiac complications Low Interm High % % 2-4-7% >3-9-11% MI, CA, death (30 day) 3.9% LOW RISK 6.0% ELEVATED RISK 10.1% 15.0% Ford et al Ann Intern Med 2010 MI, pulm edema, VF/card arrest, CHB (during hospitalization) ROC Values Total population Validation cohort Vascular surgery AAA repair 0.543
14 Revised Cardiac Risk Index (RCRI) ADVANTAGES Separates low vs high risk pts Simple, easy to use Widely used (>15 yrs) Validated externally DISADVANTAGES Underestimates risk in vascular surgery (AAA) Poor predictor of all-cause mortality Based on 25-year-old data Single institution Used CK-MB; less sensitive than troponin Broad categories for high-risk surgery and doesn t account for laparoscopic or endovascular procedures Few pts with recent MI or AS Doesn t include functional capacity May be improved by using creat clear<30, adding age and/or ASA, eliminating DM
15 MI/Cardiac Arrest Risk Calculator ( Gupta et al. Circulation 2011;124:381-7 Used NSQIP database - multivariate logistic regression Developed from 2007 data - 211,410 pts Validated with 2008 data - 257,385 pts 5 predictors of MI/card arrest 1) Type of surgery (21 categories) 2) Dependent functional status 3) Abnormal creatinine (>1.5 mg/dl) 4) ASA class 5) Increasing age Database RCRI VSGNE MICA Risk calculator Vasc surg
16 Smartphone/iPad Version on QxMD
17 MI/Cardiac Arrest Risk Calculator ADVANTAGES Better discriminative or predictive ability for MI/CA than RCRI or VSGNE-CRI Exact model-based estimate More surgery-specific than RCRI DISADVANTAGES NSQIP lacks data on known/remote CAD, stress test/echo, AS, BB May miss NSTEMIs (<3xULM troponin) Need smartphone or computer
18 ACS NSQIP Surgical Risk Calculator Bilimoria et al. J Am Coll Surg 2013;217:833-42
19
20 ACS NSQIP Surgical Risk Calculator
21 ACS NSQIP Universal Surgical Risk Calculator ADVANTAGES Covers almost all operations across multiple subspecialties Includes surgeon adjustment score to modify risk estimates Offers benefits to patients, families, health care providers (visual display as decision aid for informed consent) DISADVANTAGES Same issues with NSQIP database lacking certain information More complex, more data to enter Need smartphone or computer May not be as accurate as procedure-specific calculators (colorectal) Tendency for predicted risk to be overestimated for lowest and highest risk pts and underestimated for moderate risk pts (but was recently recalibrated) Does not account for the indication for the procedure #Periop2018
22 Comparison of Cardiac Risk Calculators
23 BOTTOM LINE All calculators appear to work reasonably well to categorize patients as low or elevated risk when used as intended. Don t use RCRI for low risk, ambulatory procedures, or AAA (+/- vascular surgery). Remember the outcomes and follow-up period: RCRI - more cardiac outcomes - only in-hospital MICA & ACS SRC - MI/cardiac arrest for 30-days postop. MICA tends to predict the lowest complication rate. ACS-SRC is the most procedure-specific and comprehensive, predicting multiple types of complications. REMEMBER: These calculators are tools to assist in shared decision making and should only be used as such. #Periop2018
24 QUESTIONS?
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