Intrathoracic, intraperitoneal, or suprainguinal vascular
History of ischemic heart disease
History of MI or positive exercise test, current chest pain due to ischemia, use of nitrate therapy, or ECG with pathological Q waves
History of heart failure
History of heart failure, pulmonary edema, or paroxysmal nocturnal dyspnea; physical examination showing bilateral rales or S3 gallop; or chest radiograph showing pulmonary vascular redistribution
History of cerebrovascular disease
History of transient ischemic attack or stroke
Diabetes requiring preoperative insulin
Chronic kidney disease
Preoperative serum creatinine >2 mg/dL (>177 µmol/L / >1.5 mg/dL in some definitions)
RCRI —
Answer yes/no to each risk factor
Instructions
The Revised Cardiac Risk Index (RCRI) helps clinicians estimate the risk of major cardiac complications in patients undergoing non-cardiac surgery. It is calculated by assessing six independent predictors, each scoring 1 point if present. The total score stratifies patients into risk categories for myocardial infarction, pulmonary edema, ventricular fibrillation, cardiac arrest, or complete heart block. Clinicians should evaluate risk factors during preoperative assessment and use the RCRI alongside clinical judgment, surgical risk, and patient comorbidities to guide perioperative management.
Overview
When to use
Why use
Evidences
IInterpretation
RCRI Score
Estimated Risk of Major Cardiac Complications
0
Very Low Risk (<1%)
1
Low Risk (~1%)
2
Intermediate Risk (~6%)
≥3
High Risk (≥10%)
The Revised Cardiac Risk Index (RCRI) was derived and prospectively validated in 4,315 patients ≥50 years undergoing major noncardiac surgery; six independent predictors each add 1 point: high-risk surgery (intraperitoneal, intrathoracic, suprainguinal vascular), ischemic heart disease, heart failure, cerebrovascular disease, insulin-dependent diabetes, and serum creatinine >2.0 mg/dL
Risk rises with the number of predictors: class I (0 factors) ≈0.4%, class II (1) ≈0.9%, class III (2) ≈6–7%, class IV (≥3) ≈11% risk of major cardiac complications in the original cohorts, and these strata are commonly used in practice and validations
Contemporary external validations show RCRI retains acceptable discrimination for perioperative major adverse cardiac events (MACE), but calibration can vary by population and surgery type; performance is more limited for vascular procedures, where vascular-specific tools (e.g., VSG-CRI) may be preferable
The 2024 AHA/ACC perioperative guideline endorses using validated calculators such as RCRI or ACS-NSQIP tools within a stepwise evaluation; many protocols consider RCRI >1 or estimated MACE risk >1% as thresholds to escalate testing or optimize management
The Revised Cardiac Risk Index (RCRI) is one of the most widely used clinical tools for preoperative risk stratification in patients undergoing non-cardiac surgery. Originally derived and validated by Lee et al. in 1999, the RCRI was designed to identify patients at increased risk of perioperative cardiac complications and to aid in perioperative decision-making.
The RCRI assigns 1 point each for the presence of six risk factors: high-risk surgery (e.g., intraperitoneal, intrathoracic, or suprainguinal vascular procedures), history of ischemic heart disease, history of congestive heart failure, history of cerebrovascular disease (stroke or transient ischemic attack), diabetes mellitus requiring insulin, and preoperative serum creatinine greater than 2.0 mg/dL. The total score (0–6) is then used to stratify patients into risk categories for major adverse cardiac events (MACE).
Patients with 0 risk factors are considered low risk, with an estimated rate of cardiac complications under 1%. Those with higher scores face progressively greater risks, with patients scoring 3 or more considered high risk and warranting careful perioperative evaluation, optimization, and possible additional testing or interventions.
Overview
When to use
Why use
Evidences
IInterpretation
RCRI Score
Estimated Risk of Major Cardiac Complications
0
Very Low Risk (<1%)
1
Low Risk (~1%)
2
Intermediate Risk (~6%)
≥3
High Risk (≥10%)
The Revised Cardiac Risk Index (RCRI) was derived and prospectively validated in 4,315 patients ≥50 years undergoing major noncardiac surgery; six independent predictors each add 1 point: high-risk surgery (intraperitoneal, intrathoracic, suprainguinal vascular), ischemic heart disease, heart failure, cerebrovascular disease, insulin-dependent diabetes, and serum creatinine >2.0 mg/dL
Risk rises with the number of predictors: class I (0 factors) ≈0.4%, class II (1) ≈0.9%, class III (2) ≈6–7%, class IV (≥3) ≈11% risk of major cardiac complications in the original cohorts, and these strata are commonly used in practice and validations
Contemporary external validations show RCRI retains acceptable discrimination for perioperative major adverse cardiac events (MACE), but calibration can vary by population and surgery type; performance is more limited for vascular procedures, where vascular-specific tools (e.g., VSG-CRI) may be preferable
The 2024 AHA/ACC perioperative guideline endorses using validated calculators such as RCRI or ACS-NSQIP tools within a stepwise evaluation; many protocols consider RCRI >1 or estimated MACE risk >1% as thresholds to escalate testing or optimize management
