Systematic review: prediction of perioperative cardiac complications and mortality by the revised cardiac risk index.
BACKGROUND
The Revised Cardiac Risk Index (RCRI) is widely used to predict perioperative cardiac complications.


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


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


METHODS
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.


METHODS
Two reviewers independently extracted study characteristics, documented outcome data, and evaluated study quality.


RESULTS
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 (I(2) = 95%).


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


CONCLUSIONS
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.
Ford
Meredith K
MK
Toronto General Hospital and University of Toronto, Toronto, Ontario, Canada.
Beattie
W Scott
WS
Wijeysundera
Duminda N
DN
D002423:Cause of Death; D006323:Heart Arrest / Q000453:epidemiology* / Q000401:mortality; D006801:Humans; D009203:Myocardial Infarction / Q000453:epidemiology* / Q000401:mortality; D011183:Postoperative Complications / Q000453:epidemiology*; D018570:Risk Assessment / Q000379:methods*; D012307:Risk Factors; D014656:Vascular Surgical Procedures