Abstract
Background
The Revised Cardiac Risk Index (RCRI) is widely used to estimate risk of cardiac complications
after noncardiac surgery; its estimates do not capture myocardial injury after noncardiac
surgery (MINS). We evaluated the incidence of cardiac complications including MINS
across RCRI risk classes and the RCRI's ability to discriminate, before surgery, between
patients who will experience these complications and those who will not.
Methods
This was a secondary analysis of a prospective cohort study of 35,815 patients ≥ 45
years old who had elective inpatient noncardiac surgery from 2007 to 2013 at 28 centres
in 14 countries. The primary outcome was a composite of MINS, myocardial infarction,
nonfatal cardiac arrest, or cardiac death within 30 days after surgery. The secondary
outcome was this composite without MINS.
Results
The primary outcome occurred in 4725 patients (13.2%); its incidences across RCRI
classes I (no risk factors), II (1 risk factor), III (2 risk factors), and IV (≥ 3
risk factors) were, respectively, 8.2%, 15.4%, 26.6%, and 40.2% (C-statistic for discrimination
0.65 [95% confidence interval 0.62-0.68]). The secondary outcome occurred in 1174
patients (3.3%) with incidences of 1.6%, 4.0%, 7.9%, and 12.9%, respectively (C-statistic
0.69 [0.65-0.72]). Thirty-five percent of primary outcome events and 26.9% of secondary
outcome events occurred in patients with no RCRI risk factors.
Conclusion
The RCRI alone is not sufficient to guide postoperative cardiac monitoring because
1 in 12 patients ≥ 45 years of age without any RCRI risk factors have a cardiac complication
after major noncardiac surgery, and most of them would be missed without systematic
troponin testing.
Résumé
Contexte
L'indice de risque cardiaque révisé (IRCR) est couramment utilisé pour estimer le
risque de complications après une chirurgie non cardiaque; son estimation ne tient
cependant pas compte des lésions myocardiques après une chirurgie non cardiaque (LMCNC).
Nous avons évalué l'incidence des complications cardiaques, y compris les LMCNC, dans
toutes les classes de risque définies par l'IRCR et la capacité de l'IRCR de permettre
de distinguer, avant une chirurgie, les patients qui présenteront de telles complications
de ceux qui n'en présenteront pas.
Méthodologie
La présente étude était une analyse secondaire d'une étude de cohorte prospective
de 35 815 patients âgés de 45 ans et plus ayant subi une chirurgie non cardiaque ambulatoire
non urgente entre 2007 et 2013 dans 28 centres situés dans 14 pays. Le critère d’évaluation
principal était un critère composite tenant compte des LMCNC, de l'infarctus du myocarde,
de l'arrêt cardiaque non fatal et de la mort de cause cardiaque survenue dans les
30 jours suivant la chirurgie. Le critère d’évaluation secondaire était ce critère
composite à l'exclusion des LMCNC.
Résultats
Le critère d’évaluation principal a été observé chez 4 725 patients (13,2 %); son
incidence dans les classes d'IRCR I (pas de facteur de risque), II (un facteur de
risque), III (duex facteurs de risque) et IV (≥ trois facteurs de risque) était respectivement
de 8,2 %, 15,4 %, 26,6 % et 40,2 % (statistique C de la discrimination : 0,65 [intervalle
de confiance à 95 % : de 0,62 à 0,68]). Le critère d’évaluation secondaire a été observé
chez 1 174 patients (3,3 %) avec une incidence dans les différentes classes d'IRCR
de 1,6 %, 4,0 %, 7,9 % et 12,9 %, respectivement (statistique C : 0,69 [intervalle
de confiance à 95 % : de 0,65 à 0,72]). Trente-cinq pour cent des événements du critère
d’évaluation principal et 26,9 % des événements du critère d’évaluation secondaire
sont survenus chez des patients ne présentant pas de facteur de risque pris en compte
dans l'IRCR.
Conclusions
L'IRCR seul n'est pas suffisant pour orienter la surveillance cardiaque postopératoire,
car un patient sur 12 âgé de 45 ans et plus n'ayant pas de facteur de risque pris
en compte dans l'IRCR présente une complication cardiaque après une chirurgie non
cardiaque majeure, et la majorité de ces cas passeraient inaperçus sans un dosage
systématique de la troponine.
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Canadian Journal of CardiologyAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- An estimation of the global volume of surgery: a modelling strategy based on available data.Lancet. 2008; 372: 139-144
- Association between complications and death within 30 days after noncardiac surgery.CMAJ. 2019; 191: E830-E837
- Myocardial injury after noncardiac surgery: a large, international, prospective cohort study establishing diagnostic criteria, characteristics, predictors, and 30-day outcomes.Anesthesiology. 2014; 120: 564-578
- Association of postoperative high-sensitivity troponin levels with myocardial injury and 30-day mortality among patients undergoing noncardiac surgery.JAMA. 2017; 317: 1642-1651
- 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.Circulation. 2014; 130: e278-e333
- 2014 ESC/ESA guidelines on noncardiac surgery: cardiovascular assessment and management: the Joint Task Force on noncardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA).Eur J Anaesthesiol. 2014; 31: 517-573
- Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery.Circulation. 1999; 100: 1043-1049
- Canadian Cardiovascular Society guidelines on perioperative cardiac risk assessment and management for patients who undergo noncardiac surgery.Can J Cardiol. 2017; 33: 17-32
- Perioperative cardiac events in patients undergoing noncardiac surgery: a review of the magnitude of the problem, the pathophysiology of the events and methods to estimate and communicate risk.CMAJ. 2005; 173: 627-634
- Underutilization of perioperative screening for cardiovascular events after noncardiac surgery in Alberta.Can J Cardiol. 2021; 37: 57-65
- External validation of the Revised Cardiac Risk Index and update of its renal variable to predict 30-day risk of major cardiac complications after noncardiac surgery: rationale and plan for analyses of the VISION study.BMJ Open. 2017; 7e013510
- Third universal definition of myocardial infarction.Circulation. 2012; 126: 2020-2035
- An empirical evaluation of the predictive mean matching method for imputing missing values.Sociol Methods Res. 1997; 26: 3-33
- Applied Logistic Regression.3rd ed. John Wiley & Sons, Hoboken2013
- A note on robust variance estimation for cluster-correlated data.Biometrics. 2000; 56: 645-646
- Sample size considerations for the external validation of a multivariable prognostic model: a resampling study.Stat Med. 2016; 35: 214-226
- Substantial effective sample sizes were required for external validation studies of predictive logistic regression models.J Clin Epidemiol. 2005; 58: 475-483
- Sex differences in ischemic heart disease: advances, obstacles, and next steps.Circ Cardiovasc Qual Outcomes. 2018; 11e004437
- Sex differences in lifetime risk and first manifestation of cardiovascular disease: prospective population based cohort study.BMJ. 2014; 349: g5992
- Systematic review: prediction of perioperative cardiac complications and mortality by the revised cardiac risk index.Ann Intern Med. 2010; 152: 26-35
- The Vascular Study Group of New England Cardiac Risk Index (VSG-CRI) predicts cardiac complications more accurately than the Revised Cardiac Risk Index in vascular surgery patients.J Vasc Surg. 2010; 52 (e1): 674-683
- Dabigatran in patients with myocardial injury after noncardiac surgery (MANAGE): an international, randomised, placebo-controlled trial.Lancet. 2018; 391: 2325-2334
- Characteristics and short-term prognosis of perioperative myocardial infarction in patients undergoing noncardiac surgery: a cohort study.Ann Intern Med. 2011; 154: 523-528
Article info
Publication history
Published online: March 22, 2021
Accepted:
March 17,
2021
Received:
December 28,
2020
Footnotes
See page 1223 for disclosure information.
Identification
Copyright
© 2021 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
ScienceDirect
Access this article on ScienceDirectLinked Article
- A Simple, Reliable, and Validated Preoperative Cardiac Risk IndexCanadian Journal of CardiologyVol. 37Issue 8
