Predicting major adverse cardiac events in spine fusion patients: is the revised cardiac risk index sufficient?
METHODS
Observational cohort study.


OBJECTIVE
To determine the accuracy of the Revised Cardiac Risk Index (RCRI) in predicting major adverse cardiac events in patients undergoing spine fusion surgery of 3 levels or more.


BACKGROUND
Preoperative cardiac testing is extensively guided by the RCRI, which was developed and validated in thoracic, abdominal, and orthopedic surgical patients. Because multilevel spine fusion surgery is often associated with major transfusion, we hypothesize that the RCRI may not accurately characterize the risk of cardiovascular morbidity in these patients.


METHODS
After institutional review board approval, perioperative data were collected from 547 patients who underwent 3 or more levels of spinal fusion with instrumentation. Postoperative cardiac morbidity was defined as any combination of the following: arrhythmia requiring medical treatment, myocardial infarction (either by electrocardiographic changes or troponin elevation), or the occurrence of demand ischemia. The surgical complexity was categorized as anterior surgery only, posterior cervical and/or thoracic fusion, posterior lumbar fusion, or any surgery that included transpedicular osteotomies. Logistic regression analysis was performed to determine RCRI performance.


RESULTS
The RCRI performed no better than chance (area under the curve = 0.54) in identifying the 49 patients (9%) who experienced cardiac morbidity.


CONCLUSIONS
The RCRI did not predict cardiac morbidity in our patients undergoing major spine fusion surgery, despite being extensively validated in low-risk noncardiac surgical patients. Preoperative testing and optimization decisions, previously based on the RCRI, may need to be revised to include more frequent functional cardiac imaging and more aggressive implementation of pharmacologic modalities that may mitigate cardiac morbidity, similar to the preoperative evaluation for major vascular surgery.


METHODS
3.
Departments of *Anesthesiology †Neurology, and ‡Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL; and §Department of Anesthesiology, American University of Beirut Medical Center, Beirut, Lebanon.
Louanne M
LM
Carabini
Carine
C
Zeeni
Natalie C
NC
Moreland
Robert W
RW
Gould
Laura B
LB
Hemmer
John F
JF
Bebawy
Tyler R
TR
Koski
Jamal
J
McClendon
Antoun
A
Koht
Dhanesh K
DK
Gupta
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D005260:Female; D006321:Heart / Q000503:physiopathology; D006331:Heart Diseases / Q000209:etiology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000209:etiology*; D011237:Predictive Value of Tests; D018570:Risk Assessment / Q000379:methods; D012307:Risk Factors; D013123:Spinal Fusion / Q000009:adverse effects*; D014656:Vascular Surgical Procedures