RCRI Calculator (Revised Cardiac Risk Index)

The Lee Index for perioperative cardiac risk stratification. Predicts major adverse cardiac events (MACE) within 30 days of non-cardiac surgery.

Important Clinical Disclaimer: The RCRI Calculator is intended for use by qualified healthcare professionals only. It is for educational and informational purposes and should not replace clinical judgement. Always interpret results alongside the full clinical picture and follow your local guidelines and protocols.
RCRI Risk Factors

Select all risk factors that apply to the patient:

RCRI Risk Stratification
Score Class MACE Risk*
0 I 0.4%
1 II 0.9%
2 III 6.6%
≥3 IV ≥11%

*MACE = Major Adverse Cardiac Events: cardiac death, non-fatal MI, non-fatal cardiac arrest

Surgical Risk Categories
High Risk (>5% MACE)
  • Aortic and major vascular surgery
  • Peripheral arterial surgery
Intermediate Risk (1-5%)
  • Intraperitoneal surgery
  • Intrathoracic surgery
  • Carotid endarterectomy
  • Head and neck surgery
  • Orthopaedic surgery
  • Prostate surgery
Low Risk (<1%)
  • Endoscopic procedures
  • Superficial procedures
  • Cataract surgery
  • Breast surgery
  • Ambulatory surgery
Functional Capacity (METs)
1 MET Eating, dressing, using toilet
4 METs Climbing 1 flight of stairs, walking on level ground at 6 km/h, heavy housework
10 METs Strenuous sports (swimming, tennis, football)
Patients achieving ≥4 METs without symptoms generally have adequate cardiac reserve for most non-cardiac surgery.

Preoperative Cardiac Assessment Algorithm

ESC/ESA 2022 Guidelines Approach:
Step 1

Emergency surgery?

If yes → proceed to surgery with perioperative risk stratification and optimisation where possible

Step 2

Active cardiac conditions?

Unstable angina, decompensated HF, severe arrhythmias, severe valvular disease → evaluate and treat before elective surgery

Step 3

Calculate RCRI

Assess surgical risk category and functional capacity (METs)

Step 4

Consider further testing?

Only if RCRI ≥2, poor functional capacity, and result would change management

When to Consider Further Cardiac Testing

Testing Generally NOT Indicated
  • Low-risk surgery (regardless of RCRI)
  • RCRI 0-1 with good functional capacity
  • Emergency surgery (proceed with optimisation)
  • Results would not change management
  • Patient declines intervention regardless
Consider Testing If
  • RCRI ≥2 AND poor functional capacity (<4 METs)
  • High-risk surgery with clinical risk factors
  • New or changing cardiac symptoms
  • Results would change perioperative management
  • Consideration of preoperative revascularisation

Testing options: stress ECG, stress echocardiography, myocardial perfusion imaging, or coronary CT angiography

Perioperative Medication Management

Medication Recommendation Notes
Beta-blockers Continue if already taking Do not start de novo within 24h of surgery. If starting, titrate over weeks.
Statins Continue perioperatively Consider starting in vascular surgery if not already on statin
ACE inhibitors/ARBs Consider withholding on day of surgery Associated with perioperative hypotension; restart when euvolaemic
Aspirin Balance risks Continue in patients with coronary stents (discuss with cardiology). Otherwise, may stop 7 days before if bleeding risk high.
P2Y12 inhibitors Discuss with cardiology Dual antiplatelet therapy after stent: involve cardiology for timing decisions
Anticoagulants Bridging decisions individualised Based on indication, bleeding risk, and surgical procedure

Frequently Asked Questions

RCRI has some limitations depending on surgery type:

  • Vascular surgery: RCRI may underestimate risk. Consider using the Vascular Study Group of New England (VSGNE) cardiac risk index or adding B-type natriuretic peptide (BNP) testing.
  • Low-risk surgery: RCRI adds little value as baseline risk is already very low.
  • Emergency surgery: Less validated; clinical judgement paramount.

The ACS NSQIP Surgical Risk Calculator may provide more procedure-specific estimates and includes additional variables like functional status and ASA class.

No. Routine stress testing is not recommended based on RCRI alone. Consider testing only when:

  • RCRI ≥2 AND poor functional capacity (<4 METs)
  • AND results would genuinely change management (e.g., consideration of preoperative revascularisation or cancellation of surgery)

Studies have shown that routine preoperative coronary revascularisation does not reduce perioperative cardiac events in stable CAD, so testing should be targeted to patients where intervention is genuinely being considered.

Cardiac biomarkers can add prognostic information to RCRI:

  • Preoperative BNP/NT-proBNP: Elevated levels (>300 pg/mL for BNP, >900 pg/mL for NT-proBNP) independently predict perioperative cardiac events. Consider in patients with RCRI ≥1 undergoing intermediate/high-risk surgery.
  • Postoperative troponin: Routine postoperative troponin monitoring (days 1-3) in high-risk patients can detect myocardial injury after non-cardiac surgery (MINS), which has prognostic significance even without symptoms.

ESC guidelines support biomarker use in intermediate-high risk patients for enhanced risk stratification.

Frailty is an independent predictor of perioperative complications not captured by RCRI:

  • Frail patients have 2-3x higher risk of postoperative complications
  • Associated with prolonged hospital stay, discharge to care facilities, and mortality
  • Consider formal frailty assessment (e.g., Clinical Frailty Scale, Edmonton Frail Scale) in elderly patients

RCRI combined with frailty assessment provides more comprehensive risk estimation in older surgical patients. Prehabilitation may improve outcomes in frail patients undergoing elective surgery.

Patients with coronary stents require careful perioperative antiplatelet management:

  • Bare-metal stent (BMS): Minimum 1 month dual antiplatelet therapy (DAPT) before elective surgery
  • Drug-eluting stent (DES): Minimum 6 months DAPT (12 months after ACS) before elective surgery
  • If surgery urgent: Continue aspirin if possible; discuss P2Y12 inhibitor cessation timing with cardiology and balance stent thrombosis risk vs bleeding risk

Perioperative stent thrombosis carries very high mortality (~45%). Involve the cardiology team in all decisions regarding antiplatelet management in stented patients.

Disclaimer

This calculator is provided for educational and informational purposes only. It is not intended to be a substitute for professional medical advice, diagnosis, or treatment.

  • Always seek the advice of a qualified healthcare provider with any questions regarding a medical condition.
  • Never disregard professional medical advice or delay seeking it because of information from this tool.
  • Clinical decision-making should always incorporate the full clinical context, patient preferences, and local protocols.
  • The creators of this tool accept no liability for decisions made based on its output.

If you are a patient: please discuss any results with your healthcare provider. This tool is designed for use by medical professionals and may not be appropriate for self-assessment.

References

  1. Lee TH, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. 1999;100(10):1043-1049. doi:10.1161/01.CIR.100.10.1043
  2. Halvorsen S, et al. 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery. Eur Heart J. 2022;43(39):3826-3924. doi:10.1093/eurheartj/ehac270
  3. Fleisher LA, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery. Circulation. 2014;130(24):e278-e333.
  4. Duceppe E, et al. Canadian Cardiovascular Society Guidelines on Perioperative Cardiac Risk Assessment and Management for Patients Who Undergo Noncardiac Surgery. Can J Cardiol. 2017;33(1):17-32.
  5. NICE. Perioperative care in adults (NG180). 2020. https://www.nice.org.uk/guidance/ng180
  6. Devereaux PJ, et al. Association of Postoperative High-Sensitivity Troponin Levels With Myocardial Injury and 30-Day Mortality Among Patients Undergoing Noncardiac Surgery. JAMA. 2017;317(16):1642-1651.