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• W2129226196 abstract "Cardiovascular risk prediction using clinical risk factors is integral to both the European and the American algorithms for preoperative cardiac risk assessment and perioperative management for non-cardiac surgery. We have reviewed these risk factors and their ability to guide clinical decision making. We examine their limitations and attempt to identify factors which may improve their performance when used for clinical risk stratification. To improve the performance of the clinical risk factors, it is necessary to create uniformity in the definitions of both cardiovascular outcomes and the clinical risk factors. The risk factors selected should reflect the degree of organ dysfunction rather than a historical diagnosis. Parsimonious model design should be applied, making use of a minimal number of continuous variables rather than creating overfitted models. The inclusion of age in the model may assist partly in controlling for the duration of risk factor exposure. Risk assignment should occur throughout the perioperative period and the risk factors chosen for model inclusion should vary depending on when the assignment occurs (before operation, intraoperatively, or after operation). Cardiovascular risk prediction using clinical risk factors is integral to both the European and the American algorithms for preoperative cardiac risk assessment and perioperative management for non-cardiac surgery. We have reviewed these risk factors and their ability to guide clinical decision making. We examine their limitations and attempt to identify factors which may improve their performance when used for clinical risk stratification. To improve the performance of the clinical risk factors, it is necessary to create uniformity in the definitions of both cardiovascular outcomes and the clinical risk factors. The risk factors selected should reflect the degree of organ dysfunction rather than a historical diagnosis. Parsimonious model design should be applied, making use of a minimal number of continuous variables rather than creating overfitted models. The inclusion of age in the model may assist partly in controlling for the duration of risk factor exposure. Risk assignment should occur throughout the perioperative period and the risk factors chosen for model inclusion should vary depending on when the assignment occurs (before operation, intraoperatively, or after operation). Editor's key points•Cardiovascular risk prediction is a desirable objective in anaesthesia.•All current approaches have some limitations and lack specificity for an individual patient.•The use of additional variables, such as age, is proposed.•Risk assessment should be repeated through the perioperative period and not just preoperatively. •Cardiovascular risk prediction is a desirable objective in anaesthesia.•All current approaches have some limitations and lack specificity for an individual patient.•The use of additional variables, such as age, is proposed.•Risk assessment should be repeated through the perioperative period and not just preoperatively. Preoperative risk stratification as stated by the American College of Cardiology/American Heart Association (ACC/AHA)1Fleisher LA Beckman JA Brown KA et al.ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery): Developed in Collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery.Circulation. 2007; 116: 1971-1996doi:10.1161/CIRCULATIONAHA.107.185700Crossref PubMed Scopus (564) Google Scholar in their ‘Perioperative cardiovascular evaluation and care for noncardiac surgery’ is aimed at ‘providing a risk profile’ while the European Society of Cardiology/European Society of Anaesthesiology's (ESC/ESA) guidelines for preoperative cardiac risk assessment aim to generate an ‘individualized cardiac risk assessment’.2Poldermans D Bax JJ Boersma E et al.Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery: the Task Force for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Management in Non-cardiac Surgery of the European Society of Cardiology (ESC) and endorsed by the European Society of Anaesthesiology (ESA).Eur Heart J. 2009; 30: 2769-2812doi:10.1093/eurheartj/ehp337Crossref PubMed Scopus (716) Google Scholar These risk assessments are then used to assist with both short- and long-term patient investigation and to direct further perioperative management. Clinical risk factors play an important role in this process, providing a cheap and readily accessible tool by which to perform preoperative risk stratification. The first major contribution to perioperative cardiovascular risk prediction was made when Goldman and colleagues3Goldman L Caldera DL Nussbaum SR et al.Multifactorial index of cardiac risk in noncardiac surgical procedures.N Engl J Med. 1977; 297: 845-850doi:10.1056/NEJM197710202971601Crossref PubMed Scopus (2072) Google Scholar developed the original perioperative cardiovascular risk index, later modified by Detsky and colleagues.4Detsky AS Abrams HB Forbath N Scott JG Hilliard JR Cardiac assessment for patients undergoing noncardiac surgery. A multifactorial clinical risk index.Arch Intern Med. 1986; 146: 2131-2134doi:10.1001/archinte.146.11.2131Crossref PubMed Scopus (413) Google Scholar Subsequent indices showed similar performance in predicting cardiovascular risk5Gilbert K Larocque BJ Patrick LT Prospective evaluation of cardiac risk indices for patients undergoing noncardiac surgery.Ann Intern Med. 2000; 133: 356-359Crossref PubMed Scopus (119) Google Scholar until the development of Lee's Revised Cardiac Risk Index (RCRI).6Lee TH Marcantonio ER Mangione CM et al.Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery.Circulation. 1999; 100: 1043-1049Crossref PubMed Scopus (2645) Google Scholar The RCRI performed significantly better than previous indices and was validated outside its derivation population (Table 1).7Boersma E Kertai MD Schouten O et al.Perioperative cardiovascular mortality in noncardiac surgery: validation of the Lee cardiac risk index.Am J Med. 2005; 118: 1134-1141doi:10.1016/j.amjmed.2005.01.064Abstract Full Text Full Text PDF PubMed Scopus (278) Google Scholar This led to its incorporation into the ACC/AHA perioperative algorithm, and also into the ESC/ESA guidelines for preoperative cardiac risk assessment and management for non-cardiac surgery. This has established the RCRI as the primary clinical cardiovascular risk stratification tool in perioperative medicine.1Fleisher LA Beckman JA Brown KA et al.ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery): Developed in Collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery.Circulation. 2007; 116: 1971-1996doi:10.1161/CIRCULATIONAHA.107.185700Crossref PubMed Scopus (564) Google Scholar 2Poldermans D Bax JJ Boersma E et al.Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery: the Task Force for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Management in Non-cardiac Surgery of the European Society of Cardiology (ESC) and endorsed by the European Society of Anaesthesiology (ESA).Eur Heart J. 2009; 30: 2769-2812doi:10.1093/eurheartj/ehp337Crossref PubMed Scopus (716) Google ScholarTable 1Cardiovascular outcomes associated with Lee's RCRI. CVS, cardiovascular. Clinical risk factors include high-risk surgery, ischaemic heart disease, history of congestive cardiac failure, history of cerebrovascular disease, insulin therapy for diabetes, and a preoperative serum creatinine of >177 μmol litre−1.6Lee TH Marcantonio ER Mangione CM et al.Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery.Circulation. 1999; 100: 1043-1049Crossref PubMed Scopus (2645) Google ScholarNumber of CVS risk factorsMajor CVS complications (95% CI)6Lee TH Marcantonio ER Mangione CM et al.Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery.Circulation. 1999; 100: 1043-1049Crossref PubMed Scopus (2645) Google Scholar (%)Cardiovascular death7Boersma E Kertai MD Schouten O et al.Perioperative cardiovascular mortality in noncardiac surgery: validation of the Lee cardiac risk index.Am J Med. 2005; 118: 1134-1141doi:10.1016/j.amjmed.2005.01.064Abstract Full Text Full Text PDF PubMed Scopus (278) Google Scholar (%)00.5 (0.2–1.1)0.311.3 (0.7–2.1)0.723.6 (2.1–5.6)1.7≥39.1 (5.5–13.8)3.6 Open table in a new tab The aim of this review is to evaluate the utility and limitations of the RCRI clinical risk factors as they are currently used in preoperative evaluation guidelines for risk stratification and directing further preoperative investigation.1Fleisher LA Beckman JA Brown KA et al.ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery): Developed in Collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery.Circulation. 2007; 116: 1971-1996doi:10.1161/CIRCULATIONAHA.107.185700Crossref PubMed Scopus (564) Google Scholar 2Poldermans D Bax JJ Boersma E et al.Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery: the Task Force for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Management in Non-cardiac Surgery of the European Society of Cardiology (ESC) and endorsed by the European Society of Anaesthesiology (ESA).Eur Heart J. 2009; 30: 2769-2812doi:10.1093/eurheartj/ehp337Crossref PubMed Scopus (716) Google Scholar We have attempted to identify areas of clinical risk prediction which could be improved on in the future. The goal of preoperative risk assessment is to assess an individual patient's cardiac risk in order to direct further testing and treatment, and to perform this process as cost-effectively as possible. Current perioperative cardiovascular evaluation algorithms follow a stepwise process making use of clinical factors and test results together with an estimation of the size of the surgical stress response to arrive at an ‘individualized cardiac risk assessment’.1Fleisher LA Beckman JA Brown KA et al.ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery): Developed in Collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery.Circulation. 2007; 116: 1971-1996doi:10.1161/CIRCULATIONAHA.107.185700Crossref PubMed Scopus (564) Google Scholar 2Poldermans D Bax JJ Boersma E et al.Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery: the Task Force for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Management in Non-cardiac Surgery of the European Society of Cardiology (ESC) and endorsed by the European Society of Anaesthesiology (ESA).Eur Heart J. 2009; 30: 2769-2812doi:10.1093/eurheartj/ehp337Crossref PubMed Scopus (716) Google Scholar The first four steps in both the European and American guidelines are directed at assessing patient-specific risk. These steps determine (i) the presence of active or unstable cardiac conditions, (ii) the patient's functional capacity, (iii) the urgency, and (iv) associated cardiac risk of the surgery. They are tailored to the individual patient and the surgery they have to undergo. The presence of active cardiac conditions, high-risk surgery, or poor effort tolerance all greatly increases a patient's risk for a postoperative cardiac complication. Patients are then clinically stratified using the RCRI clinical risk factors.6Lee TH Marcantonio ER Mangione CM et al.Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery.Circulation. 1999; 100: 1043-1049Crossref PubMed Scopus (2645) Google Scholar In contrast to the preceding steps of the algorithms, the RCRI is a population-derived risk index. As a result, it cannot be used to assign individual patient risk but is rather used to stratify patients into risk categories, which forms the basis for further perioperative management. To perform this role adequately, the RCRI risk factors must successfully discriminate higher risk from lower risk patients in this already triaged population. Two statistical methods may be used to evaluate the discrimination of the RCRI. The first is by means of likelihood ratios (LRs). LRs reflect a test's ability to create risk categories, by expressing these categories as ratios. Clinically useful discrimination is seen with ratios <0.2 or >10.8Ridley S Cardiac scoring systems'what is their value?.Anaesthesia. 2003; 58: 985-991doi:10.1046/j.1365-2044.2003.03342.xCrossref PubMed Scopus (35) Google Scholar An added advantage of the LR is that it may be used to determine post-test probability, using Fagan's nomogram.9Fagan TJ Letter: nomogram for Bayes theorem.N Engl J Med. 1975; 293: 257Crossref PubMed Scopus (48) Google Scholar The second commonly used method is the area under the receiver-operating characteristic (ROC) curve (AUC).10Pencina MJ D'Agostino Sr, RB D'Agostino Jr, RB Vasan RS Evaluating the added predictive ability of a new marker: from area under the ROC curve to reclassification and beyond.Stat Med. 2008; 27 (discussion 207–12): 157-172doi:10.1002/sim.2929Crossref PubMed Scopus (4766) Google Scholar The AUC (also known as the c-statistic) is expressed as a percentage and reflects the probability that a positive test will experience an event when compared with a negative test.10Pencina MJ D'Agostino Sr, RB D'Agostino Jr, RB Vasan RS Evaluating the added predictive ability of a new marker: from area under the ROC curve to reclassification and beyond.Stat Med. 2008; 27 (discussion 207–12): 157-172doi:10.1002/sim.2929Crossref PubMed Scopus (4766) Google Scholar The ACC/AHA guidelines use the RCRI to create three risk categories (3 or more, 1 or 2, no risk factors) to guide further investigation, while the ESC guidelines make use of only two risk categories (≥3 risk factors or <3 risk factors).1Fleisher LA Beckman JA Brown KA et al.ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery): Developed in Collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery.Circulation. 2007; 116: 1971-1996doi:10.1161/CIRCULATIONAHA.107.185700Crossref PubMed Scopus (564) Google Scholar 2Poldermans D Bax JJ Boersma E et al.Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery: the Task Force for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Management in Non-cardiac Surgery of the European Society of Cardiology (ESC) and endorsed by the European Society of Anaesthesiology (ESA).Eur Heart J. 2009; 30: 2769-2812doi:10.1093/eurheartj/ehp337Crossref PubMed Scopus (716) Google Scholar An assessment of the RCRI determined that the only clinically significant LRs were achieved when a patient had no clinical risk factors (LR of 0.16).8Ridley S Cardiac scoring systems'what is their value?.Anaesthesia. 2003; 58: 985-991doi:10.1046/j.1365-2044.2003.03342.xCrossref PubMed Scopus (35) Google Scholar The presence of one risk factor fell just outside the clinically useful range with a negative LR of 0.34. For patients with either two, or three and more risk factors, the discrimination was found to be poor with an LR of 2.7 and 4.8, respectively.8Ridley S Cardiac scoring systems'what is their value?.Anaesthesia. 2003; 58: 985-991doi:10.1046/j.1365-2044.2003.03342.xCrossref PubMed Scopus (35) Google Scholar When applied to a large retrospective database study (108593 patients) of non-cardiac surgery population, the RCRI was able to discriminate four individual risk groups in which the risk of cardiac death was statistically different (0.3%, 0.7%, 1.7%, 3.6%). However, the clinical utility of these findings is questionable as the resultant c-statistic for the AUC was only 0.63.7Boersma E Kertai MD Schouten O et al.Perioperative cardiovascular mortality in noncardiac surgery: validation of the Lee cardiac risk index.Am J Med. 2005; 118: 1134-1141doi:10.1016/j.amjmed.2005.01.064Abstract Full Text Full Text PDF PubMed Scopus (278) Google Scholar To improve on this discriminatory ability, patients have been grouped into low (0 or 1 risk factors) and intermediate–high (≥2 risk factors) risk categories. The ability of the RCRI to predict perioperative cardiac complications [cardiac death, myocardial infarction (MI), non-fatal cardiac arrest] or death within 30 days of surgery was reviewed in a recent large meta-analysis of predominantly observational cohort studies (792740 patients in 24 studies).11Ford MK Beattie WS Wijeysundera DN Systematic review: prediction of perioperative cardiac complications and mortality by the revised cardiac risk index.Ann Intern Med. 2010; 152: 26-35Crossref PubMed Scopus (341) Google Scholar It found moderate discrimination between patients at high vs low risk for cardiac events [AUC 0.75 (95% CI 0.72–0.79), with a positive LR of 2.78 (95% CI 1.74–4.45) and a negative LR of 0.45 (95% CI 0.31–0.67)]. When used for vascular surgery alone, the RCRI showed significantly poorer discrimination for predicting cardiac events in this meta-analysis, than with other types of non-cardiac surgery, with an AUC of 0.64 (95% CI 0.61–0.66), a positive LR of 1.56 (95% CI 1.42–1.73), and a negative LR of 0.55 (95% CI 0.53–0.82).11Ford MK Beattie WS Wijeysundera DN Systematic review: prediction of perioperative cardiac complications and mortality by the revised cardiac risk index.Ann Intern Med. 2010; 152: 26-35Crossref PubMed Scopus (341) Google Scholar Interestingly, these findings echo those in Lee's original prospective observational study of 4315 non-cardiac surgical patients aged ≥50 yr, where they identified the limited discriminative utility of the RCRI in aortic surgery [AUC 0.543 (0.092)].6Lee TH Marcantonio ER Mangione CM et al.Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery.Circulation. 1999; 100: 1043-1049Crossref PubMed Scopus (2645) Google Scholar Other data also suggest that the performance of the RCRI is influenced by the nature of the surgical procedure and is particularly compromised by higher risk surgeries. A retrospective database review found that the separation of low-to-intermediate risk surgeries from the intermediate-to-high-risk surgeries changed the AUC from 0.68 to 0.56, respectively.7Boersma E Kertai MD Schouten O et al.Perioperative cardiovascular mortality in noncardiac surgery: validation of the Lee cardiac risk index.Am J Med. 2005; 118: 1134-1141doi:10.1016/j.amjmed.2005.01.064Abstract Full Text Full Text PDF PubMed Scopus (278) Google Scholar A recent prospective observational study of 10081 vascular surgical patients, which evaluated the same patient outcomes of the original RCRI confirmed that with vascular surgical procedures of increasing cardiovascular risk, the RCRI progressively underestimated the associated cardiovascular complications.12Bertges DJ Goodney PP Zhao Y et al.The Vascular Study Group of New England Cardiac Risk Index (VSG-CRI) predicts cardiac complications more accurately than the Revised Cardiac Risk Index in vascular surgery patients.J Vasc Surg. 2010; 52 (683 e1–3): 674-683doi:10.1016/j.jvs.2010.03.031Abstract Full Text Full Text PDF PubMed Scopus (167) Google Scholar Thus, the RCRI, as a preoperative population-derived risk stratification tool, is at best able to crudely risk stratify patients. In addition, the RCRI's discrimination is best in patients with no risk factors, and not in the higher risk categories as used in the ACC/AHA or the ESC guidelines,8Ridley S Cardiac scoring systems'what is their value?.Anaesthesia. 2003; 58: 985-991doi:10.1046/j.1365-2044.2003.03342.xCrossref PubMed Scopus (35) Google Scholar 11Ford MK Beattie WS Wijeysundera DN Systematic review: prediction of perioperative cardiac complications and mortality by the revised cardiac risk index.Ann Intern Med. 2010; 152: 26-35Crossref PubMed Scopus (341) Google Scholar or in vascular surgical patients.6Lee TH Marcantonio ER Mangione CM et al.Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery.Circulation. 1999; 100: 1043-1049Crossref PubMed Scopus (2645) Google Scholar 11Ford MK Beattie WS Wijeysundera DN Systematic review: prediction of perioperative cardiac complications and mortality by the revised cardiac risk index.Ann Intern Med. 2010; 152: 26-35Crossref PubMed Scopus (341) Google Scholar It would seem that the RCRI's greatest utility lies in its ability to exclude low-risk patients rather than in predicting events in intermediate-to-high-risk patients. Indeed, the need to undertake high-quality studies to evaluate the RCRI's ability to predict perioperative cardiac risk has been suggested,11Ford MK Beattie WS Wijeysundera DN Systematic review: prediction of perioperative cardiac complications and mortality by the revised cardiac risk index.Ann Intern Med. 2010; 152: 26-35Crossref PubMed Scopus (341) Google Scholar and Goldman13Goldman L The revised cardiac risk index delivers what it promised.Ann Intern Med. 2010; 152: 57-58Crossref PubMed Scopus (7) Google Scholar in his editorial on the paper suggests that the RCRI is accurate enough for preoperative risk stratification, although he too suggests that it may benefit from an improvement in its diagnostic accuracy. The poor discrimination in high-risk (≥3 risk factors) patients would not be a concern, if subsequent non-invasive testing was able to reliably risk stratify these patients. Unfortunately, the evidence suggests that non-invasive investigations are not able to do this. A single, prospective, randomized trial of 208 vascular surgical patients has addressed this issue. In patients with ≥2 RCRI risk factors, one group was managed as per the AHA/ACC preoperative cardiovascular algorithm and selectively underwent coronary angiography following non-invasive testing. All the patients in the other arm of the study had preoperative coronary angiography.14Monaco M Stassano P Di Tommaso L et al.Systematic strategy of prophylactic coronary angiography improves long-term outcome after major vascular surgery in medium- to high-risk patients: a prospective, randomized study.J Am Coll Cardiol. 2009; 54: 989-996doi:10.1016/j.jacc.2009.05.041Crossref PubMed Scopus (125) Google Scholar While the groups were clinically similar, the myocardial revascularization rate and survival at 58 (17) months was significantly better in the group randomized to routine coronary angiography.14Monaco M Stassano P Di Tommaso L et al.Systematic strategy of prophylactic coronary angiography improves long-term outcome after major vascular surgery in medium- to high-risk patients: a prospective, randomized study.J Am Coll Cardiol. 2009; 54: 989-996doi:10.1016/j.jacc.2009.05.041Crossref PubMed Scopus (125) Google Scholar Essentially, non-invasive testing was unable to identify those patients who may have benefited from coronary angiography and revascularization. Meta-analyses of studies of non-invasive testing suggest that the discriminatory performance of these tests is clinically poor with LR ranging from 2 to 6.15Biccard BM Rodseth RN The pathophysiology of perioperative myocardial infarction.Anaesthesia. 2010; 65: 733-741doi:10.1111/j.1365-2044.2010.06338.xCrossref PubMed Scopus (59) Google Scholar 16Kertai MD Boersma E Bax JJ et al.A meta-analysis comparing the prognostic accuracy of six diagnostic tests for predicting perioperative cardiac risk in patients undergoing major vascular surgery.Heart. 2003; 89: 1327-1334doi:10.1136/heart.89.11.1327Crossref PubMed Scopus (224) Google Scholar While a number of the studies included in the meta-analyses of non-invasive tests were not necessarily done after RCRI specific risk stratification, many used clinical risk factors to risk stratify before non-invasive tests. There are clearly limitations to non-invasive tests. As we have shown, the positive LR for patients with ≥3 risk factors decreases below the clinically significant threshold. In addition, the pretest probability of the populations selected by the algorithm for further testing is probably lower than expected and it is possible that this may be further contributing to their poor performance. If we could improve the performance of clinical risk prediction, we may also improve the performance of preoperative non-invasive tests. Unfortunately, we are unaware of any perioperative study which has tested this hypothesis. With our current approach to risk stratification, it is true that ‘we are not yet near the situation where we can give a specific risk value for an individual’,17Reilly CS Can we accurately assess an individual's perioperative risk?.Br J Anaesth. 2008; 101: 747-749doi:10.1093/bja/aen314Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar although this is what we should strive for. There are three broad categories of shortcomings that underlie the current poor performance of clinical cardiovascular risk prediction models. These include: (i) the definition of both clinical risk factors and adverse cardiovascular outcomes, (ii) the limitations of identified risk factors, and (iii) the statistical flaws in model derivation. These shortcomings can be identified in many aspects of the original work on cardiovascular risk prediction and are discussed below. Risk factor definition has varied between derivation studies and the subsequent application of these models. The classic example is the risk factor ‘preoperative treatment with insulin’ adopted by Lee and colleagues6Lee TH Marcantonio ER Mangione CM et al.Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery.Circulation. 1999; 100: 1043-1049Crossref PubMed Scopus (2645) Google Scholar in the RCRI. It has been changed to ‘insulin-dependent diabetes mellitus’18Auerbach A Goldman L Assessing and reducing the cardiac risk of noncardiac surgery.Circulation. 2006; 113: 1361-1376doi:10.1161/CIRCULATIONAHA.105.573113Crossref PubMed Scopus (125) Google Scholar and in the ACC/AHA guidelines to ‘diabetes mellitus’.1Fleisher LA Beckman JA Brown KA et al.ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery): Developed in Collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery.Circulation. 2007; 116: 1971-1996doi:10.1161/CIRCULATIONAHA.107.185700Crossref PubMed Scopus (564) Google Scholar These variations make comparisons between different studies difficult and may hamper model performance and applicability.11Ford MK Beattie WS Wijeysundera DN Systematic review: prediction of perioperative cardiac complications and mortality by the revised cardiac risk index.Ann Intern Med. 2010; 15" @default.
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• W2129226196 title "Utility of clinical risk predictors for preoperative cardiovascular risk prediction" @default.
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