Original article
General thoracic
Recalibration of the Revised Cardiac Risk Index in Lung Resection Candidates

Presented at the Forty-sixth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 25–27, 2010.
https://doi.org/10.1016/j.athoracsur.2010.03.042Get rights and content

Background

The revised cardiac risk index (RCRI) has been proposed as a tool for cardiac risk stratification before lung resection. However, the RCRI was originally developed from a generic surgical population including a small group of thoracic patients. The objective of this study was to recalibrate the RCRI in candidates for major lung resections to provide a more specific instrument for cardiac risk stratification.

Methods

One thousand six hundred ninety-six patients who underwent lobectomy (1,426) or pneumonectomy (270) in two centers between the years of 2000 and 2008 were analyzed. Stepwise logistic regression and bootstrap analyses were used to recalibrate the six variables comprising the RCRI. The outcome variable was occurrence of major cardiac complications (cardiac arrest, complete heart block, acute myocardial infarction, pulmonary edema, or cardiac death during admission). Only those variables with a probability of less than 0.1 in more than 50% of bootstrap samples were retained in the final model and proportionally weighted according to their regression estimates.

Results

The incidence of major cardiac morbidity was 3.3% (57 patients). Four of the six variables present in the RCRI were reliably associated with major cardiac complications: cerebrovascular disease (1.5 points), cardiac ischemia (1.5 points), renal disease (1 point), and pneumonectomy (1.5 points). Patients were grouped into four classes according to their recalibrated RCRI, predicting an incremental risk of cardiac morbidity (p < 0.0001). Compared with the traditional RCRI, the recalibrated score had a higher discrimination (c indexes, 0.72 versus 0.62; p = 0.004).

Conclusions

The recalibrated RCRI can be reliably used as a first-line screening instrument during cardiologic risk stratification for selecting those patients needing further cardiologic testing from those who can proceed with pulmonary evaluation without any further cardiac tests.

Section snippets

Patients and Methods

This is an observational study performed on prospectively collected data in two dedicated thoracic surgery centers. The study was approved by the local hospital institutional review boards, and patients gave their consent to collection and use of their data in the database for clinical and scientific purposes.

All 1,696 major lung resections (1,426 pulmonary lobectomies and 270 pneumonectomies) performed from January 2000 through December 2008 for benign, primary malignant, or metastatic disease

Results

The characteristics of the patients in this study are displayed in Table 1. There were 69 major cardiac complications in 57 patients (cumulative incidence, 3.3%): 36 pulmonary edema, 11 acute myocardial infarctions, 6 cardiac arrests, and 16 cardiac-related deaths (of 48 total deaths).

Logistic regression showed that only four of the six variables present in the original RCRI were reliably associated with major cardiac complications in this setting (Table 2).

According to their regression

Comment

Recently published guidelines from international medical and surgical societies have recommended the use of cardiac risk scores as screening tools for stratifying the cardiac risk of patients undergoing noncardiac surgery. The European Respiratory Society/European Society of Thoracic Surgeons task force for evaluating fitness of lung resection candidates with lung cancer recommended the application of the RCRI [4] in this setting. An RCRI lower than 2 has been reported to be associated with a

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