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External Validation of the Revised Cardiac Risk Index and the Geriatric-Sensitive Perioperative Cardiac Risk Index in
Nirmeen Fayed1,2, Sally Waheed Elkhadry3, Andreas Garling1
1Anethesia and Critical Care Department, Klinikum Dortmund, Dortmund, Germany.
Insights
The Revised Cardiac Risk Index and Geriatric Sensitive Cardiac Risk Index have limited accuracy for predicting cardiac events in elderly patients undergoing spinal anesthesia. Improving these indices with factors like age, atrial fibrillation, and trauma surgery enhances their predictive power, especially for the GSCRI.
Area of Science:
- Cardiology
- Geriatric Medicine
- Anesthesiology
Background:
- The Revised Cardiac Risk Index (RCRI) and Geriatric Sensitive Cardiac Risk Index (GSCRI) assess postoperative major adverse cardiac events (MACE) risk.
- These indices do not specify risk in elderly patients (≥80 years) undergoing surgery, particularly under spinal anesthesia (SA).
Purpose of the Study:
- To test the external validity of RCRI and GSCRI in patients aged 80 and above undergoing surgery with SA.
- To identify additional risk factors for postoperative MACE in this demographic.
Main Methods:
- Evaluated the discrimination, calibration, and clinical utility of RCRI and GSCRI for predicting in-hospital MACE.
- Investigated correlations with ICU admission and length of hospital stay (LOS).
- Developed multivariable models incorporating identified risk factors (age, AF, trauma surgery).
Main Results:
- MACE incidence was 7.5%; both indices showed limited predictive ability (AUC ~0.69).
- Atrial fibrillation (AF), trauma surgery, and age >80 were significant MACE predictors.
- Multivariable models improved discrimination (AUC up to 0.798), with multivariate GSCRI showing better predictive ability and clinical utility.
- Both indices poorly correlated with ICU admission and LOS.
Conclusions:
- RCRI and GSCRI have limited predictive value for MACE in oldest-old patients undergoing SA.
- Incorporating age, AF, and trauma surgery significantly improved the GSCRI's performance and clinical utility.
- Multivariate GSCRI demonstrated superior predictive accuracy and clinical utility compared to multivariate RCRI in this population.
Background:
The Revised Cardiac Risk Index (RCRI) and the Geriatric Sensitive Cardiac Risk Index (GSCRI) estimate the risk of postoperative major adverse cardiac events (MACE) regardless of the type of anesthesia and without specifying the oldest old patients. Since spinal anesthesia (SA) is a preferred technique in geriatrics, we aimed to test the external validity of these indices in patients ≥ 80 years old who underwent surgery under SA and tried to identify other potential risk factors for postoperative MACE.
Methods:
The performance of both indices to estimate postoperative in-hospital MACE risk was tested through discrimination, calibration, and clinical utility. We also investigated the correlation between both indices and postoperative ICU admission and length of hospital stay (LOS).
Results:
The MACE incidence was 7.5%. Both indices had limited discriminative (AUC for RCRI and GSCRI were 0.69 and 0.68, respectively) and predictive abilities. The regression analysis showed that patients with atrial fibrillation (AF) were 3.77 and those with trauma surgery were 2.03 times more likely to exhibit MACE, and the odds of MACE increased by 9% for each additional year above 80. Introducing these factors into both indices (multivariable models) increased the discriminative ability (AUC reached 0.798 and 0.777 for RCRI and GSCRI, respectively). Bootstrap analysis showed that the predictive ability of the multivariate GSCRI but not the multivariate RCRI improved. Decision curve analysis (DCA) showed that multivariate GSCRI had superior clinical utility when compared with multivariate RCRI. Both indices correlated poorly with postoperative ICU admission and LOS.
Conclusion:
Both indices had limited predictive and discriminative ability to estimate postoperative in-hospital MACE risk and correlated poorly with postoperative ICU admission and LOS, following surgery under SA in the oldest-old patients. Updated versions by introducing age, AF, and trauma surgery improved the GSCRI performance but not the RCRI.
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