Objective assessment of cardiac risk for noncardiac surgical patients: an up-to-date simplified approach.

In the current issue of Circulation, Gupta et al1 describe a new model for the prediction of cardiac risk after noncardiac surgery. The authors note that perioperative myocardial infarction varies considerably from patient to patient and from procedure to procedure and is associated with very significant morbidity and mortality. The thrust of their argument is that, if patients at higher risk for myocardial infarction and cardiac arrest are identified preoperatively, many could potentially benefit from the optimization of their cardiac status before elective surgery, or, indeed, further consideration should be given as to whether or not an operation is advised. Goldman et al, in a very important 1977 article,2 proposed a multifactorial index for cardiac risk in noncardiac surgical procedures. This has been the gold standard for many years. This article was further modified by Lee, Goldman, et al in 1999,3 when they proposed a simple index for the prediction of cardiac risk for major noncardiac surgery (Revised Cardiac Risk Index model). Both of these risk algorithms were developed years ago, and many changes have occurred since then in the treatment of coronary artery disease, and in the anesthetic, operative, and perioperative management of noncardiac surgical patients, as well. It is therefore appropriate to have a more current model by which to objectively assess cardiac risk in this group of patients.