Revised Cardiac Risk Index (Lee Index)
The Revised Cardiac Risk Index (RCRI), also known as the Lee Index, is a validated tool for predicting major adverse cardiac events (MACE) in patients undergoing non-cardiac surgery. It assesses six independent predictors.
About
The RCRI was developed and validated by Dr. Thomas Lee and colleagues in 1999 using data from 4,315 patients undergoing elective non-cardiac surgery. It identifies six independent predictors of major cardiac complications (death, MI, pulmonary edema, VF/cardiac arrest): high-risk surgery (intraperitoneal, intrathoracic, suprainguinal vascular), ischemic heart disease (history of MI, positive stress test, angina, nitrate use, or Q waves), congestive heart failure, cerebrovascular disease (history of stroke or TIA), insulin therapy for diabetes, and pre-operative serum creatinine >2 mg/dL (177 μmol/L). The risk of MACE increases with score: 0 (0.4%), 1 (1%), 2 (2.4%), 3+ (5.4%).
Formula
RCRI = High-risk surgery (1) + Ischemic heart disease (1) + CHF (1) + Cerebrovascular disease (1) + Insulin-dependent diabetes (1) + Creatinine >2 mg/dL (1)
Each predictor scores 1 point. High-risk surgery: intraperitoneal, intrathoracic, or suprainguinal vascular. Ischemic heart disease: MI, angina, Q waves, positive stress test. CHF: pulmonary edema, S3, rales. Cerebrovascular disease: stroke or TIA. Creatinine: >2 mg/dL or >177 μmol/L.
Score Interpretation
Perioperative cardiac complications affect 1-5% of patients undergoing non-cardiac surgery and are a leading cause of post-operative mortality. The RCRI is the most widely validated cardiac risk prediction tool, endorsed by ESC/ESA guidelines for pre-operative cardiac risk assessment.
Class I — 0–0
MACE risk ~0.4%.
Management: Proceed with surgery. No additional testing needed.
Class II — 1–1
MACE risk ~1.0%.
Management: Proceed. Consider pre-operative ECG.
Class III — 2–2
MACE risk ~2.4%.
Management: Consider pre-operative testing (ECG, echo, possibly stress test).
Class IV — 3+
MACE risk ~5.4%.
Management: Cardiology consultation. Consider stress testing. Optimize cardiac medications.
Reference Ranges
| Population | Normal Range |
|---|---|
| Adults undergoing elective non-cardiac surgery | 0 (low risk) to 6 (high risk) |
Pharmacy+ Medical Review Team
Expert cardiology review panel.
View medical review board & editorial policy →Example Calculation
A 75-year-old with prior MI, diabetes on insulin, undergoing open repair of AAA (high-risk surgery). RCRI: high-risk surgery (1) + ischemic heart disease (1) + insulin diabetes (1) = 3 (Class IV, 5.4% MACE risk).
Related Conditions
Related Medications
Common Mistakes
Counting previous coronary revascularization as ischemic heart disease without active ischemia.
RCRI counts ischemic heart disease only if active (MI, angina, Q waves, positive stress test, or nitrate use). Prior CABG without active symptoms is not counted.
Frequently Asked Questions
Is RCRI still recommended in current guidelines?
References
- Lee TH, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. 1999;100(10):1043-9.
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