Revised cardiac risk index and adverse outcomes in patients undergoing surgical stabilization of rib fractures

Surgical stabilization of rib fractures (SSRF) is increasingly performed in patients with severe rib fractures or flail chest. It has been shown to reduce ventilator days and pulmonary complications. Nevertheless, SSRF carries perioperative morbidity, particularly pulmonary and cardiac events, and the optimal preoperative cardiac risk stratification tool for this population has not been established. This study evaluated the association between the Revised Cardiac Risk Index (RCRI) and in-hospital mortality and cardiopulmonary complications in SSRF patients.

This retrospective cohort study used the ACS-TQIP National Trauma Data Bank (2019-2023) to identify adult patients undergoing SSRF. Patients with AIS ≥ 2 in non-thoracic regions, blunt cardiac injury (AIS ≥ 2), or aortic injury were excluded. Because SSRF is an intrathoracic procedure, each patient carried a minimum RCRI of 1; patients were stratified into RCRI = 1, RCRI = 2, and RCRI ≥ 3. The primary outcomes were in-hospital mortality and a composite of cardiopulmonary complications (myocardial infarction, cardiac arrest, pneumonia, ARDS, deep vein thrombosis, and pulmonary embolism). Modified Poisson regression with robust standard errors estimated adjusted risk ratios (RRs), with RCRI = 1 as the reference and adjustment for demographics, regional and chest AIS, fixation details, and comorbidities.

After exclusions, 6,139 patients were analyzed (RCRI = 1, n = 4,678; RCRI = 2, n = 1,208; RCRI ≥ 3, n = 253). Adverse outcomes increased stepwise with higher RCRI in both unadjusted and adjusted analyses. Compared with RCRI = 1, RCRI ≥ 3 was associated with significantly higher adjusted risks of in-hospital mortality (RR 3.34, 95% CI 2.06-5.43, p <0.001) and cardiopulmonary complications (RR 3.42, 95% CI 2.08-5.62; both p < 0.001), as well as myocardial infarction (RR 9.28, 95% CI 2.84-30.34, p < 0.001) and pneumonia (RR 5.85, 95% CI 2.72-12.59, p < 0.001). RCRI = 2 was also associated with increased mortality (RR 2.13, 95% CI 1.50-3.04, p < 0.001) and cardiopulmonary complications (RR 1.72, 95% CI 1.20-2.48, p = 0.003).

RCRI is a simple, readily available bedside tool that independently stratifies the risk of in-hospital mortality and cardiopulmonary complications in patients undergoing SSRF. Incorporating the RCRI into preoperative assessment may help identify high-risk patients and guide perioperative management.