Estimates the risk of a major cardiac complication around major noncardiac surgery from six factors.
Result
Answer the six questions to see the score.
Sources
3 studies
3
studies
3,795
citations
964
PubMed papers
Evidence
Known limitations
In 24 studies with 792,740 patients, the index discriminated moderately well after mixed noncardiac surgery (area under the curve 0.75) but poorly after vascular surgery (0.64) and for predicting death (median 0.62).
Ann Intern Med: Journal Metrics Score 4.6, Q1 · cited 557 times
The Canadian guideline recommends measuring BNP or NT-proBNP before surgery when the RCRI is 1 or more, the patient is 65 or older, or is 45 to 64 with significant cardiovascular disease, and advises against routine preoperative stress testing, echocardiography or coronary CT for risk estimation.
Can J Cardiol: Journal Metrics Score 1.1, Q3 · cited 845 times
The 2024 American perioperative guideline uses a validated risk tool such as the RCRI together with functional capacity to decide whether further evaluation is needed before elective noncardiac surgery, and supports BNP or NT-proBNP to refine risk in patients with poor or unknown capacity.
Circulation: Journal Metrics Score 2.3, Q2 · cited 471 times
The original paper has been cited 3,795 times, and 964 PubMed articles mention the Revised Cardiac Risk Index in their title or abstract. Citation counts from OpenAlex and article counts from PubMed, retrieved November 15, 2026. Journal Metrics Scores and quartiles are from this site’s current release; follow the journal name for details.
After the result
Any patient · Score 1 or more · Score 0
Look for an active cardiac condition first. Refine the risk. Usually proceed.
Next steps
Avoid common errors
5 common errors to avoid
and 3 more
When the index misleads
1Elective surgery only
The index was built on elective operations and underestimates risk in emergency surgery.
2Older rates are too low
Lee’s 0.4% for class I came from a cohort without routine troponin screening. Studies that measure troponin after surgery find more myocardial injury and higher event rates.
3Diabetes on tablets does not count
Only insulin-treated diabetes scores a point.
4Vascular surgery
The index discriminates poorly after vascular surgery (area under the curve 0.64 in a systematic review).
5Not functional capacity
The score ignores how much the patient can do. Poor exercise tolerance adds risk the index does not capture.
Formula
One point each for six factors; class I (0), II (1), III (2), IV (3 or more).
One point each for six factors; class I (0), II (1), III (2), IV (3 or more).
Factors and risk classes
| Factor | Definition |
|---|---|
| High-risk surgery | Intraperitoneal, intrathoracic or suprainguinal vascular surgery. Laparoscopic and thoracoscopic operations in these cavities are usually counted (Lee 1999 did not address them). |
| Ischemic heart disease | Previous myocardial infarction, a positive exercise test, current angina, nitrate use, or Q waves on the ECG. Previous PCI or CABG counts only with one of these. |
| Heart failure | History of heart failure, pulmonary edema or paroxysmal nocturnal dyspnea; bilateral rales or an S3 on examination; or pulmonary vascular redistribution on the chest X-ray. |
| Cerebrovascular disease | Previous stroke or transient ischemic attack. |
| Diabetes treated with insulin | Insulin before surgery. Diabetes on tablets or diet alone does not count. |
| Creatinine above 2 mg/dL (177 µmol/L) | Preoperative serum creatinine above 2.0 mg/dL (177 µmol/L). |
| Class | Factors | Lee 1999 | Canadian guideline 2017 |
|---|---|---|---|
| Class I | 0 | 0.4% | 3.9% |
| Class II | 1 | 0.9% | 6.0% |
| Class III | 2 | 7% | 10.1% |
| Class IV | 3 or more | 11% | 15.0% |
Lee 1999: major cardiac complications in the validation cohort of 1,422 patients. Canadian guideline: 30-day death, myocardial infarction or cardiac arrest, from studies with routine troponin screening.
Lee 1999
High-risk surgery
Creatinine
Test cases
3 published cases, each also a test case
3 published cases; the calculator reproduces every score.
Worked examples
A man in his late 70s with esophageal cancer had no diabetes, no hypertension and no cardiovascular history, could manage 4 METs or more, and had a normal ECG and echocardiogram. CT showed heavily calcified coronary arteries. During a mediastinoscope-assisted transhiatal esophagectomy he had pulseless ventricular tachycardia needing chest compressions. It settled within about 20 seconds but left ST depression, and angiography found a diffuse 90% stenosis of the left anterior descending artery, treated with balloon angioplasty and a stent.
“Our patient had no cardiovascular history and an RCRI of 1.”
The one point is for the esophagectomy (intrathoracic and intraperitoneal surgery). The authors note that, looking back, the coronary calcification on CT deserved further assessment despite the low score.
Entered as: High-risk surgery: Yes (1); Ischemic heart disease: No (0); Heart failure: No (0); Cerebrovascular disease: No (0); Diabetes treated with insulin: No (0); Creatinine above 2 mg/dL (177 µmol/L): No (0).
Source: Maruyama K et al., Gen Thorac Cardiovasc Surg Cases 2023 (PubMed · Free full text · DOI)
A 46-year-old man with severe mitral stenosis (NYHA class III breathlessness) and a cardioembolic stroke two years earlier, on warfarin, needed both a right lower lobectomy for bronchiectasis and mitral valve replacement. His effort tolerance was about 4 METs. The team did the lobectomy first and the valve replacement later.
“the Revised cardiac risk index (RCRI) score of the patient was 2”
Intrathoracic surgery 1 and previous stroke 1. The report does not list which factors were counted; surgery and stroke account for both points, which implies the breathlessness from mitral stenosis was not counted as heart failure. Severe symptomatic valve disease needs assessment in its own right, whatever the score.
Entered as: High-risk surgery: Yes (1); Ischemic heart disease: No (0); Heart failure: No (0); Cerebrovascular disease: Yes (1); Diabetes treated with insulin: No (0); Creatinine above 2 mg/dL (177 µmol/L): No (0).
Source: Venkatesh Thiruvengadam V et al., Ann Card Anaesth 2024 (PubMed · Free full text · DOI)
A 74-year-old man with a previous anterior myocardial infarction, coronary bypass surgery and dilated cardiomyopathy with advanced heart failure (ejection fraction about 15%) needed surgery for colorectal cancer. He had insulin-treated diabetes, chronic kidney disease (GFR 35 mL/min) and peripheral vascular disease. The operation was done with an Impella heart pump in place, which was removed shortly afterwards; he needed 2 days of inotropic support and went home after a week.
“The Revised Cardiac Risk Index for preoperative risk was 5”
The report does not list which factors were counted or give the creatinine. The operation, ischemic heart disease, heart failure and insulin give 4 points. The fifth is most likely his kidney disease (GFR 35 mL/min): the European version of the score counts creatinine clearance below 60 mL/min. The example scores it as the creatinine item.
Entered as: High-risk surgery: Yes (1); Ischemic heart disease: Yes (1); Heart failure: Yes (1); Cerebrovascular disease: No (0); Diabetes treated with insulin: Yes (1); Creatinine above 2 mg/dL (177 µmol/L): Yes (1).
Source: Guarracini S et al., Front Cardiovasc Med 2024 (PubMed · Free full text · DOI)
FAQ
6 questions and answers
and 4 more answers
Questions
High-risk surgery (intraperitoneal, intrathoracic or suprainguinal vascular), ischemic heart disease, heart failure, cerebrovascular disease (stroke or TIA), diabetes treated with insulin, and a preoperative creatinine above 2 mg/dL (177 µmol/L). Each scores 1 point.
In Lee’s 1999 validation cohort, major cardiac complications occurred in 0.4% of patients with no factors, 0.9% with one, 7% with two and 11% with three or more. Later studies that screen with troponin after surgery find higher rates: the Canadian guideline estimates 3.9%, 6.0%, 10.1% and 15.0% for 30-day death, myocardial infarction or cardiac arrest.
Yes. It was published by Lee and colleagues in 1999 as a revision of the Goldman cardiac risk index, and it is often called the Lee index or Lee criteria.
Guidelines differ. The Canadian guideline recommends BNP or NT-proBNP before surgery for patients with an RCRI of 1 or more, aged 65 or older, or aged 45 to 64 with significant cardiovascular disease, and advises against routine stress testing or echocardiography for risk estimation. American (2024) and European (2022) guidelines combine a risk tool with functional capacity. Both support measuring BNP or NT-proBNP in patients at higher risk, and the European guideline recommends troponin before and 24 and 48 hours after intermediate- or high-risk surgery in patients with cardiovascular disease or risk factors. Stress testing is for patients whose results would change management.
It was built on elective operations, so it underestimates risk in emergency surgery. Urgent operations should not be delayed for cardiac testing unless an unstable cardiac condition needs treatment first.
A systematic review found that the RCRI discriminated moderately well after mixed noncardiac surgery (area under the curve 0.75) but poorly after vascular surgery (0.64). Many vascular patients have coronary disease that the factors do not capture, and only suprainguinal vascular operations score the surgery point.
Further reading
8 references with PubMed and DOI links
8
references
3
free full text
From Lee TH et al., Circulation 1999 to the newest case reports.
References
clinical grade of aneurysmal subarachnoid hemorrhage, I to V.
total calcium adjusted for albumin, in mg/dL or mmol/L.
stroke severity from 15 bedside items, 0 to 42.
MAP from systolic and diastolic pressure, against the 65 mm Hg target.
eye, verbal and motor scores for preverbal children, 3 to 15.
oxygenation ratio with the Berlin ARDS severity ranges.
serum sodium corrected for high glucose, Katz or Hillier factor.
sodium − (chloride + bicarbonate), with the albumin-corrected gap.
urea nitrogen to creatinine ratio, in US or SI units.
estimated creatinine clearance with actual, ideal or adjusted weight.
cardiac output and index from oxygen consumption and saturations.
ANC from the white cell count, neutrophils and bands.
insulin resistance from fasting glucose and insulin, in US or SI units.
FENa from plasma and urine sodium and creatinine: prerenal, indeterminate or tubular pattern.
three-item stroke severity screen for large vessel occlusion, 0 to 4.
water deficit in hypernatremia from sodium, weight and body water.
expected PaCO2 in metabolic acidosis, 1.5 × HCO3 + 8 ± 2.
corrected QT interval by Bazett, Fridericia, Framingham or Hodges.
head CT decision rule for children with minor head trauma.
blood loss before hemoglobin or hematocrit reaches a chosen lowest value.
eye, verbal and motor response, 3 to 15, with GCS-Pupils.
Devine ideal body weight and adjusted weight from height and sex.
cuffed and uncuffed tube size and oral depth by age.
calculated osmolality, osmolal gap and ethanol correction.
severity of alcohol-associated hepatitis from prothrombin time and bilirubin.
MELD, MELD-Na and MELD 3.0 for chronic liver disease.
early stroke risk after a transient ischemic attack.
whether a patient with blunt trauma needs cervical spine imaging.
prognosis from a Bruce protocol exercise test.
alveolar–arterial oxygen gradient from a blood gas.
whether an adult with minor head injury needs CT.
risk of advanced liver fibrosis from age, AST, ALT and platelets.
6-week risk of a major cardiac event in emergency chest pain.
whether a pleural effusion is an exudate or a transudate.
pre-test probability of pulmonary embolism, with the D-dimer step.
urine output by weight, KDIGO oliguria stage and fluid balance.
Contributed by Dr. Meng Zhao (MD · Former Neurosurgeon · Medical AI Researcher), from the original publications listed here. Last updated November 15, 2026. LinkedIn
The calculator code is tested against every worked example on this page before each release.
This calculator supports, and does not replace, clinical judgment. It is meant for healthcare professionals and is not medical advice for patients. Report an error through the contact page.