RCRI (Lee Index) Calculator

RCRI Calculator

Check all 6 risk factors that apply. Score updates automatically.

1High-risk surgery — intraperitoneal, intrathoracic, or suprainguinal vascular surgery +1

2Ischaemic heart disease — prior MI, positive stress test, chest pain due to suspected ischaemia, nitrate use, or ECG with Q waves +1

3Congestive heart failure — pulmonary oedema, bilateral rales, S3 gallop, PND, or CXR with pulmonary vascular redistribution +1

4Cerebrovascular disease — prior TIA or stroke +1

5Pre-operative insulin-dependent diabetes mellitus +1

6Pre-operative serum creatinine >2.0 mg/dL (177 µmol/L) +1

Very Low Cardiac Risk

0.4%

MACE Risk

Proceed

Recommendation

Score 0: MACE risk 0.4%. Proceed to surgery without further cardiac evaluation.

The Six RCRI Predictors

1. Surgery	High-risk surgery: intraperitoneal, intrathoracic, or suprainguinal vascular — each carries a significantly higher cardiac event rate than superficial or orthopaedic procedures
2. IHD	Ischaemic heart disease: prior MI, positive exercise stress test, typical angina, use of sublingual nitrate, or ECG showing pathological Q waves
3. CHF	Congestive heart failure: pulmonary oedema, bilateral basal crackles, S3 gallop, paroxysmal nocturnal dyspnoea, or CXR showing upper lobe venous diversion
4. CVD	Cerebrovascular disease: history of TIA or stroke with minimal or no residual deficit
5. DM	Insulin-dependent diabetes: pre-operative insulin therapy (not diet-controlled or oral agent-only DM)
6. CKD	Creatinine >2.0 mg/dL (177 µmol/L) — reflects chronic kidney disease as a cardiovascular risk surrogate

Risk Stratification

Score	MACE Risk	Risk Class	Recommended Action
0	0.4%	Very Low	Proceed to surgery. No additional cardiac evaluation required for most patients.
1	1.0%	Low	Proceed to surgery. Optimise known comorbidities. Consider perioperative beta-blockade if already on beta-blocker.
2	2.4%	Moderate	Consider cardiology referral. Non-invasive cardiac testing (echocardiogram, stress testing) may be warranted before elective high-risk surgery.
≥3	≥5.4%	High	Cardiology referral recommended before elective surgery. Weigh risk-benefit carefully. Delay non-urgent surgery if active cardiac conditions present.

MACE = major adverse cardiac event (cardiac death, non-fatal MI, non-fatal cardiac arrest). Rates from Lee TH et al. Circulation 1999 derivation cohort.

Clinical Application

ESC/ESA 2022 Perioperative Guidelines: The RCRI remains the recommended cardiac risk index for pre-operative assessment. A score ≥2 places the patient in an intermediate-to-high risk category warranting further evaluation. Functional capacity (METs) should always be assessed alongside the RCRI.
Functional capacity: Excellent functional capacity (≥4 METs — e.g., climbing a flight of stairs, walking on level ground at 4 mph) reduces cardiac risk irrespective of RCRI score. Poor functional capacity (<4 METs) in a patient with RCRI ≥2 strongly favours pre-operative cardiac assessment.
Active cardiac conditions: Regardless of RCRI score, active cardiac conditions (unstable angina, decompensated heart failure, significant arrhythmias, severe valvular disease) must be evaluated and treated before any elective surgery.
High-risk surgery definition (criterion 1): Intraperitoneal surgery (e.g., bowel resection, hepatectomy, pancreatectomy, oesophagectomy), intrathoracic surgery, and suprainguinal vascular surgery (e.g., aortic, iliac procedures). Inguinal hernia repair, TURP, ophthalmology, and most surface procedures are low-risk and do not count.
Pre-operative beta-blockade: For patients already on beta-blockers, continue perioperatively. Do NOT initiate beta-blockers de novo on the day of surgery based on RCRI score alone — this is associated with harm (increased stroke risk per POISE trial).
NT-proBNP/BNP: In intermediate- to high-risk patients (RCRI ≥2), pre-operative NT-proBNP or BNP measurement is recommended by ESC 2022 guidelines to improve cardiac risk stratification and guide post-operative monitoring intensity.
Limitations: RCRI was derived primarily in general surgery patients. It may underestimate risk in vascular surgery patients (who tend to have higher baseline cardiovascular disease burden). Alternative tools (e.g., NSQIP MICA, ACS NSQIP calculator) may be considered in specialised contexts.

References

Lee TH, Marcantonio ER, Mangione CM, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. 1999;100(10):1043–1049.
Duceppe E, Parlow J, MacDonald P, et al. Canadian Cardiovascular Society Guidelines on Perioperative Cardiac Risk Assessment and Management for Patients Who Undergo Noncardiac Surgery. Can J Cardiol. 2017;33(1):17–32.
Halvorsen S, Mehilli J, Cassese S, et al. 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery. Eur Heart J. 2022;43(39):3826–3924.

Revised Cardiac Risk Index

The Six RCRI Predictors

Risk Stratification

Clinical Application

References

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