Clinical Utility of Revised Cardiac Risk Index to Predict Perioperative Cardiac Events in Elderly Patients with Coronary Heart Disease Undergoing Non-cardiac Surgery / 中国医学科学院学报

Objective To explore the predictive ability of the revised cardiac risk index(RCRI)in elderly patients with coronary heart disease(CHD)undergoing non-cardiac surgery. Methods We performed a retrospective study including a total of 2100 patients,aged≥65 with a history of CHD who underwent non-cardiac surgery form January 2013 to September 2019.The preoperative,intraoperative and postoperative clinical data were extracted from an electronic database.The RCRI and reconstructed-RCRI(R-RCRI)score of each patient were calculated.The primary end point was defined as an occurrence of perioperative MACE.Multivariate logistic regression analysis was performed to evaluate the risk factors of perioperative MACE.The area under the receiver operating characteristic(ROC)curve was used to compare the predictive value of RCRI,R-RCRI,and the new risk scoring system of the study for perioperative MACE. Results The incidence of perioperative MACE in elderly patients with CHD was 5.4%.Six independent risk factors of perioperative MACE for this population were identified:age≥80 years;female;history of heart failure;insulin-depended diabetes mellitus;preoperative ST segment abnormality;American Society of Anesthesiologists grade≥Ⅲ,and the risk index was 2,2,2,2,2 and 3 respectively.The area under ROC curve of RCRI,R-RCRI and risk scoring system in this study were 0.586,0.552 and 0.741. Conclusion The correlation between RCRI score and perioperative MACE was poor in elderly patients with CHD undergoing non-cardiac surgery,and a better cardiac risk assessment method should be established for this population.

Incidence and predictors of perioperative myocardial infarction in patients undergoing non-cardiac surgery in a tertiary care hospital

Background The stress in the perioperative period is compounded by unpredictable and un-physiological changes in sympathetic tone, cardiovascular performance, coagulation and inflammatory responses, all of which in turn lead to alterations in plaque morphology predisposing to perioperative myocardial infarction (PMI). PMI has a considerable morbidity and mortality in patients undergoing not only high risk surgery, but also even with minor surgical interventions. Objective To study the incidence of PMI and its predictors in patients undergoing non-cardiac surgery in a tertiary care hospital. Materials and methods Patients undergoing non-cardiac surgery were included in this prospective single-center observational study. The revised cardiac risk index (RCRI) was used for risk stratification. ECG monitoring was done for all patients. For patients suggestive of acute myocardial ischemia, echocardiography and serum troponin were evaluated. The patient was labeled as having a PMI if there was raised troponin level along with any one evidence of myocardial ischemia (symptoms, ECG changes or imaging results) and in these patients the factors predisposing to PMI were evaluated. All patients in the study were followed up to 30 days. Results Of the 525 patients analyzed, 33 patients (6.28%) had a PMI. Twelve out of the 33 (36.36%) PMI patients died within 30 days following surgery. Patients undergoing high risk surgery, smokers and patients with a past history of ischemic heart disease (IHD) were found to be at higher risk of developing PMI. The ASA physical status classification and the RCRI proved to be good predictors of PMI. Most of the PMI events (72.7%) occurred within 48 hours of surgery. Conclusion PMI is a dreaded complication associated with a very high mortality. High risk surgery, smoking and past history of ischemic heart disease were independent predictors of PMI. The RCRI is a useful tool in pre-operative risk stratification of patients.

Prognosticators of cardiac risk in non-cardiac surgery : a comparative study

A prospective study of 369 patients undergoing 375 general surgical operation was undertaken. Goldman cardiac risk index was noted to be the better prognosticator of preoperative cardiac risk in patients undergoing major non-cardiac operations as compared to ASA physical status complication. Goldmans classification avoids the 10% risk of difference of opinion among anesthesiologist and internist in the proper classification of patients. It is an objective assessment supported by clinical data. In poor risk patients, it is selective and sensitive in the sense that it identifies only 9.06% of studied population that needs more intensive hemodynamic monitoring and the care of competent anesthesiologist and cardiologist because of its high mortality rate of 41.17%. It is also observed by ASA physical status classification in the pre-operative evaluation of cardiac risk in surgery. For that reason, It was suggested that the anesthesiologist continue to use the ASA classification while the internist and the surgeon should abandon the ASA and use Goldmans classification instead. Patients evaluated as good risk patients for operation are patients in ASA Class I and II and Class I of Goldman; as fair risk if ASA Class II and Goldman Class II; and as poor risk if ASA Class III and IV and Goldman Class III. Patients in ASA Class V and Goldman Class IV are assessed as very poor risk because of 100% mortality due to all causes. In the absence ot intensive hemodynamic monitoring facilities available patients in ASA Class V and Goldman IV should not be operated even on an emergency basis