The Revised Cardiac Risk Index (RCRI, also called Lee Index) estimates the risk of major cardiac events (MI, pulmonary edema, cardiac arrest, complete heart block) after non-cardiac surgery. It uses 6 independent predictors: high-risk surgery, ischemic heart disease, congestive heart failure, cerebrovascular disease, diabetes on insulin, and creatinine > 2 mg/dL.

How is the RCRI interpreted?

Risk of major cardiac complications: 0 points: ~3.9%. 1 point: ~6%. 2 points: ~10.1%. ≥ 3 points: ~15%. Patients with RCRI ≥ 2 may benefit from further cardiac evaluation (functional capacity assessment, possibly stress testing) and perioperative beta-blocker consideration per ACC/AHA guidelines.

When should the RCRI be calculated?

RCRI should be calculated during preoperative evaluation for all patients undergoing non-cardiac surgery. It is most useful for intermediate-risk procedures. For low-risk procedures (e.g., cataract surgery), the risk is low regardless of RCRI. For emergency surgery, RCRI is less relevant as surgery cannot be delayed.

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Revised Cardiac Risk Index (RCRI)

Lee Index: 6 clinical predictors of major cardiac events after non-cardiac surgery.

Risk Factors (check all that apply)

High-risk surgery (intraperitoneal, intrathoracic, or suprainguinal vascular)

History of ischemic heart disease (MI, positive exercise test, chest pain with nitro use, ECG with Q waves; excludes prior CABG/PCI unless also has current ischemia)

History of congestive heart failure (pulmonary edema, bilateral rales/S3, paroxysmal nocturnal dyspnea, CXR with pulmonary vascular redistribution)

History of cerebrovascular disease (stroke or TIA)

Diabetes mellitus requiring insulin therapy

Preoperative serum creatinine > 2.0 mg/dL (>177 µmol/L)

RCRI = 0 risk factors. Estimated major cardiac event risk: 3.9%.

0 risk factors3.9% MACE risk

1 risk factor6.0% MACE risk

2 risk factors10.1% MACE risk

≥3 risk factors15% MACE risk

Disclaimer: Nur zu Bildungszwecken. Kein Ersatz für klinisches Urteilsvermögen.

Anwendung

Use preoperatively for patients ≥45 years (or 18–44 with significant cardiovascular disease) undergoing non-cardiac surgery to estimate risk of major cardiac events (MI, pulmonary edema, VF, cardiac arrest, complete heart block).

Klinische Praxistipps

RCRI is recommended in the 2014 ACC/AHA perioperative guidelines for risk stratification.
Patients with RCRI ≥1 and poor or unknown functional capacity may benefit from further testing (pharmacologic stress test).
The original Lee study used a composite MACE outcome — rates vary by validation cohort.

References

Lee TH, Marcantonio ER, 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.
Fleisher LA, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation. Circulation. 2014;130:e278-e333.

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What Is the RCRI?

The Revised Cardiac Risk Index (RCRI), also known as the Lee Index, is a validated preoperative risk stratification tool developed by Thomas Lee and colleagues in 1999. It simplifies the earlier Goldman and Detsky indices into six independent predictors of major perioperative cardiac events (MACE) in patients undergoing elective non-cardiac surgery. Each criterion present adds one point, and the total score (0–6) correlates with estimated MACE risk including myocardial infarction, pulmonary edema, ventricular fibrillation, cardiac arrest, and complete heart block.

The Six Criteria

The RCRI evaluates: (1) high-risk surgical procedure (intraperitoneal, intrathoracic, or suprainguinal vascular), (2) history of ischemic heart disease, (3) history of congestive heart failure, (4) history of cerebrovascular disease (stroke or TIA), (5) insulin-requiring diabetes mellitus, and (6) preoperative creatinine >2.0 mg/dL. Each criterion contributes equally. The original study reported MACE rates of 0.4%, 0.9%, 6.6%, and 11% for 0, 1, 2, and ≥3 risk factors respectively, though subsequent validations have shown somewhat higher baseline rates.

Integration Into Perioperative Guidelines

The 2014 ACC/AHA perioperative cardiovascular evaluation guidelines recommend the RCRI as a first-line risk assessment tool. Patients with RCRI 0 and adequate functional capacity (≥4 METs) can generally proceed to surgery without further cardiac testing. Those with elevated RCRI scores and poor or unknown functional capacity may benefit from pharmacologic stress testing, though routine coronary revascularization prior to non-cardiac surgery is not recommended in most scenarios.

🔑 Klinische Praxistipps

RCRI was validated for elective non-cardiac surgery — it does not apply to emergency surgery.
Functional capacity (METs) assessment should complement RCRI scoring in perioperative evaluation.
The RCRI may underestimate risk in certain high-risk populations, particularly vascular surgery patients.
BNP/NT-proBNP may add prognostic value beyond RCRI, particularly when functional capacity cannot be assessed.

Key References

Lee TH, Marcantonio ER, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk. Circulation. 1999;100(10):1043-1049.
Fleisher LA, et al. 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation. Circulation. 2014;130:e278-e333.
Duceppe E, et al. Canadian Cardiovascular Society Guidelines on Perioperative Cardiac Risk Assessment. Can J Cardiol. 2017;33(1):17-32.

Formel zuletzt überprüft: Februar 2026