Revised Cardiac Risk Index for Pre-Operative Risk

Dr. Lee Goldman on original Goldman Cardiac Risk Index for MDCalc:

The Revised Cardiac Risk Index was published 22 years after the original index became the first multifactorial approach to assessing the cardiac risk of non-cardiac surgery and one of the first such approaches for any common clinical problem. The revision was important because of major changes in the diagnosis of cardiac disease during the intervening years – especially the widespread use of echocardiography and less use of Holter monitoring. As a result, evidence of coronary disease and heart failure replaced prior reliance on the arrhythmias (both atrial and ventricular) that had been very important in the original index. Furthermore, the original index changed practice, so that previously important factors (recent MI, severe aortic stenosis) were rarely represented in the more recent cohort of patients. We had hoped that the Index would not only estimate risk but also help target certain subgroups of patients for specific beneficial interventions. The former goal has been achieved, as numerous studies have validated the Index, even if some have suggested ways to improve it in certain types of patients. The latter goal has been more elusive, since large randomized trials have failed to show benefits from preoperative coronary revascularization or perioperative beta blockade, or by extension the preoperative testing that might refine risk stratification. Whether some high risk subgroups will benefit from any of these strategies remain a subject of debate.

Lee Goldman, MD, MPH, is a professor and executive vice president for Health and Biomedical Sciences at Columbia University. He is also the dean of the Faculties of Health Sciences and Medicine at Columbia University Medical Center. Previously, he was a professor, department chair and associate dean at UCSF. Dr. Goldman researches the costs and effectiveness of diagnostic and therapeutic strategies and is well-known for applying the latest methods of multivariate analysis, cost-effectiveness, quality-of-life, and computer-simulation models to key topics in clinical medicine.

Thomas H. Lee, MD, is the chief medical officer at Press Ganey, Inc., where he leads clinical and operational strategies to enhance patient experience by reducing suffering and improving care value. He is also an internist and cardiologist practicing at Brigham and Women's Hospital in Boston and serves as a professor of medicine at Harvard Medical School.