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Systematic Review: Prediction of Perioperative Cardiac Complications and Mortality by the Revised Cardiac Risk Index

Meredith K. Ford, MD, MSc; W. Scott Beattie, MD, PhD; and Duminda N. Wijeysundera, MD
[+] Article and Author Information

From Toronto General Hospital and University of Toronto, Toronto, Ontario, Canada.


These results were presented in part at the 2008 Annual Meeting of the American Society of Anesthesiologists, 18–22 October 2008, Orlando, Florida.

Acknowledgment: The authors thank Dr. Brian Cuthbertson and Dr. David Leibowitz for providing additional unpublished information from their studies.

Grant Support: In part by a Fellowship in Anesthesia from Abbott Laboratories and the Canadian Anesthesiologists' Society (Dr. Ford) and by a Clinician Scientist award from the Canadian Institutes of Health Research and a Merit Award from the Department of Anesthesia at the University of Toronto (Dr. Wijeysundera). Dr. Beattie is the R. Fraser Elliot Chair of Cardiac Anesthesia at the University Health Network.

Potential Conflicts of Interest: None disclosed.

Requests for Single Reprints: Duminda N. Wijeysundera, MD, Department of Anesthesia, Toronto General Hospital and University of Toronto, EN 3-450, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada; e-mail, d.wijeysundera@utoronto.ca.

Current Author Addresses: Dr. Ford: Department of Anesthesia, Trillium Health Centre, 100 Queensway West, Mississauga, Ontario L5B 1B8, Canada.

Drs. Beattie and Wijeysundera: Department of Anesthesia, Toronto General Hospital and University of Toronto, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada.

Author Contributions: Conception and design: M.K. Ford, W.S. Beattie, D.N. Wijeysundera.

Analysis and interpretation of the data: M.K. Ford, W.S. Beattie, D.N. Wijeysundera.

Drafting of the article: D.N. Wijeysundera.

Critical revision of the article for important intellectual content: M.K. Ford, W.S. Beattie, D.N. Wijeysundera.

Final approval of the article: W.S. Beattie, D.N. Wijeysundera.

Statistical expertise: W.S. Beattie, D.N. Wijeysundera.

Obtaining of funding: W.S. Beattie.

Administrative, technical, or logistic support: W.S. Beattie, D.N. Wijeysundera.

Collection and assembly of data: M.K. Ford, W.S. Beattie, D.N. Wijeysundera.


Ann Intern Med. 2010;152(1):26-35. doi:10.7326/0003-4819-152-1-201001050-00007
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Background: The Revised Cardiac Risk Index (RCRI) is widely used to predict perioperative cardiac complications.

Purpose: To evaluate the ability of the RCRI to predict cardiac complications and death after noncardiac surgery.

Data Sources: MEDLINE, EMBASE, and ISI Web of Science (1966 to 31 December 2008).

Study Selection: Cohort studies that reported the association of the RCRI with major cardiac complications (cardiac death, myocardial infarction, and nonfatal cardiac arrest) or death in the hospital or within 30 days of surgery.

Data Extraction: Two reviewers independently extracted study characteristics, documented outcome data, and evaluated study quality.

Data Synthesis: Of 24 studies (792 740 patients), 18 reported cardiac complications; 6 of the 18 studies were prospective and had uniform outcome surveillance and blinded outcome adjudication. The RCRI discriminated moderately well between patients at low versus high risk for cardiac events after mixed noncardiac surgery (area under the receiver-operating characteristic curve [AUC], 0.75 [95% CI, 0.72 to 0.79]); sensitivity, 0.65 [CI, 0.46 to 0.81]; specificity, 0.76 [CI, 0.58 to 0.88]; positive likelihood ratio, 2.78 [CI, 1.74 to 4.45]; negative likelihood ratio, 0.45 [CI, 0.31 to 0.67]). Prediction of cardiac events after vascular noncardiac surgery was less accurate (AUC, 0.64 [CI, 0.61 to 0.66]; sensitivity, 0.70 [CI, 0.53 to 0.82]; specificity, 0.55 [CI, 0.45 to 0.66]; positive likelihood ratio, 1.56 [CI, 1.42 to 1.73]; negative likelihood ratio, 0.55 [CI, 0.40 to 0.76]). Six studies reported death, with a median AUC of 0.62 (range, 0.54 to 0.78). A pooled AUC for predicting death could not be calculated because of very high heterogeneity (I2 = 95%).

Limitation: Studies generally were of low methodological quality, had varied definitions of cardiac events, and were statistically and clinically heterogeneous.

Conclusion: The RCRI discriminated moderately well between patients at low versus high risk for cardiac events after mixed noncardiac surgery. It did not perform well at predicting cardiac events after vascular noncardiac surgery or at predicting death. High-quality research is needed in this area of perioperative medicine.

Primary Funding Source: None.

Figures

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Figure 1.
Literature search strategy.

AUC = area under the receiver-operating characteristic curve; RCRI = Revised Cardiac Risk Index.

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Figure 2.
AUC for predicting perioperative cardiac events and all-cause mortality.

The AUC describes the association of the Revised Cardiac Risk Index with perioperative cardiac complications (stratified by surgical procedure) and with all-cause mortality. Squares represent point estimates; the area of each square correlates with its contribution toward the weighted summary estimate. Horizontal lines denote 95% CIs. The diamonds represent the pooled estimates for the 2 subgroups. The mixed noncardiac surgery subgroup excluded one study (28) that introduced considerably increased statistical heterogeneity (I2 = 87%). The excluded study differed from the others in that it defined cardiac complications as cardiac death alone. AUC = area under the receiver-operating characteristic curve.

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Appendix Figure 1.
HSROC curve showing the accuracy of a Revised Cardiac Risk Index score of 2 or more for predicting cardiac complications after vascular noncardiac surgery.

Each individual study (27, 32, 35, 4042, 45) is represented by an open circle positioned at its estimated sensitivity and specificity. The area of each circle correlates with its contribution toward the HSROC curve. The solid black line represents the HSROC curve, with an estimated area under the curve of 0.65 (95% CI, 0.60 to 0.69). The open square represents the summary estimates for sensitivity (0.70 [CI, 0.53 to 0.82]) and specificity (0.55 [CI, 0.45 to 0.66]), and the dotted line denotes the 95% confidence region around this estimate. HSROC = hierarchical summary receiver-operating characteristic.

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Appendix Figure 2.
HSROC curve showing the accuracy of a Revised Cardiac Risk Index score of 2 or more for predicting cardiac complications after mixed noncardiac surgery.

Each individual study (7, 26, 29, 3638, 43, 46) is represented by an open circle positioned at its estimated sensitivity and specificity. The area of each circle correlates with its contribution toward the HSROC curve. The solid black line represents the HSROC curve, with an estimated area under the curve of 0.77 (95% CI, 0.73 to 0.80). The open square represents the summary estimates for sensitivity (0.65 [CI, 0.46 to 0.81]) and specificity (0.76 [CI, 0.58 to 0.88]), and the dotted line denotes the 95% confidence region around this estimate. HSROC = hierarchical summary receiver-operating characteristic.

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