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Cardiac morbidity: Pre-op factors

For more information on cardiac risk in non-cardiac surgery, see Cardiac Risk (Anesthesia Text). For more information on cardiac risk in cardiac surgery, see Risk Stratification in Cardiac Surgery.

Revised Cardiac Index

Risk factors are: history of ischemia or heart disease, CHF, CVA, Cr > 2.0, IDDM, high risk surgery [Lee et al.]

0 0.4% risk of cardiac complications
1 0.9% risk of cardiac complications
2 7% risk of cardiac complications
3 11% risk of cardiac complications

Goldman Risk Index (Historical Interest)

While RCI is the most commonly used index for non-cardiac surgery, the ABA test-taker should also be familiar with the Goldman Index, which includes third heart sound (or jugular venous distention, 11 points), MI in the preceding six months (10 points), > 5 PVCs per minute at any point before the operation or non-sinus rhythm or PACs (7 points), age > 70 (5 points), emergency (4 points) or high risk (3 points) operation, significant aortic stenosis (3 points), and “poor general medical condition” (3 points)

ACC/AHA Guidelines

ACC/AHA Guidelines suggest the following, in order:

  1. Decide whether this is an emergency surgery. If yes, proceed to OR.
  2. If there are active cardiac conditions, evaluate and treat prior to OR.

Active cardiac conditions:

  • Unstable coronary syndroms:
    • CCS III/IV (Angina/symptoms with everyday living, moderate limitation or worse)
  • Decompensated heart failure
  • Significant arrythmia:
    • High grade AV block
    • Mobitz II AV block
    • 3rd degree block
    • Symptomatic ventricular arrythmia
    • SVR with HR>100 at rest
    • Symptomatic bradycardia
    • Newly recognized ventricular tachycardia
  • Severe valvular disease:
    • Severe AS (Mean gradient >40 mmHg, aortic valve area <1 cm2, or symptomatic)
    • Symptomatic MS (DOE, exertional presyncope, or heart failure)

3. If surgery is low risk, proceed to OR.

  • Low risk: endoscopic, superficial, cataracts, breast, ambulatory
  • Intermediate risk: Intraperitoneal/Intrathoracic, carotid endarterectomy, head/neck, orthopedic, prostate
  • High risk: aortic/other major vascular procedures, peripheral vascular surgery

4. If METS => 4 without symptoms, proceed to OR.

  • METS<4: eat, dress, use toilet, walk around, walk a block or 2 on level ground slowly
  • METS=4: light housework, climb a flight of stairs
  • METS>4: walk@4 mph, run short distances, heavy housework, moderate recreational activities
  • METS>10: participate in strenuous sports

5. Examine clinical risk factors (Revised Cardiac Risk Index). If the patient has no risk factors, proceed to OR. If the patient has 1-2, proceed to OR with HR control, or consider non-invasive testing if it will change management. If the patient has 3 or more and undergoing intermediate risk surgery proceed to OR with HR control, or consider non-invasive testing if it will change management. If the patient has 3 or more and undergoing vascular surgery, consider testing if it will change management.


  1. T H Lee, E R Marcantonio, C M Mangione, E J Thomas, C A Polanczyk, E F Cook, D J Sugarbaker, M C Donaldson, R Poss, K K Ho, L E Ludwig, A Pedan, L Goldman Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation: 1999, 100(10);1043-9 PubMed Link