External validation of the Revised Cardiac Risk Index and National Surgical Quality Improvement Program Myocardial Infarction and Cardiac Arrest calculator in noncardiac vascular surgery

J Fronczek; K Polok; P J Devereaux; J Górka; R A Archbold; B Biccard; E Duceppe; Y Le Manach; D I Sessler; M Duchińska; W Szczeklik

doi:10.1016/j.bja.2019.05.029

External validation of the Revised Cardiac Risk Index and National Surgical Quality Improvement Program Myocardial Infarction and Cardiac Arrest calculator in noncardiac vascular surgery

Br J Anaesth. 2019 Oct;123(4):421-429. doi: 10.1016/j.bja.2019.05.029. Epub 2019 Jun 27.

Authors

J Fronczek¹, K Polok¹, P J Devereaux², J Górka¹, R A Archbold³, B Biccard⁴, E Duceppe², Y Le Manach⁵, D I Sessler⁶, M Duchińska¹, W Szczeklik⁷

Affiliations

¹ Department of Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland.
² Population Health Research Institute, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
³ General & Interventional Cardiology, Barts Heart Centre, St. Bartholomew's Hospital, London, UK.
⁴ Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital and University of Cape Town, South Africa.
⁵ Population Health Research Institute, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Anesthesia and Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
⁶ Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA.
⁷ Department of Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland. Electronic address: wojciech.szczeklik@uj.edu.pl.

PMID: 31256916
DOI: 10.1016/j.bja.2019.05.029

Abstract

Background: The National Surgical Quality Improvement Program Myocardial Infarction & Cardiac Arrest (NSQIP MICA) calculator and the Revised Cardiac Risk Index (RCRI) were derived using currently outdated methods of diagnosing perioperative myocardial infarctions. We tested the external validity of these tools in a setting of a systematic perioperative cardiac biomarker measurement.

Methods: Analysis of routinely collected data nested in the Vascular Events In Noncardiac Surgery Patients Cohort Evaluation Study. A consecutive sample of patients ≥45 yr old undergoing in-hospital noncardiac surgery in a single tertiary care centre was enrolled. The predictive performance of the models was tested in terms of the occurrence of major cardiac complications defined as a composite of a nonfatal myocardial infarction, a nonfatal cardiac arrest, or a cardiac death within 30 days after surgery. The plasma concentration of high-sensitivity troponin T was measured before surgery, 6-12 h after operation, and on the first, second, and third days after surgery. Myocardial infarction was diagnosed according to the Third Universal Definition.

Results: The median age was 65 (59-72) yr, and 704/870 (80.9%) subjects were male. The primary outcome occurred in 76/870 (8.7%; 95% confidence interval [CI], 6.9-10.8%) patients. The c-statistic was 0.64 (95% CI, 0.57-0.70) for the NSQIP MICA and 0.60 (95% CI, 0.54-0.65) for the RCRI. Predicted risks were systematically underestimated in calibration belts (P<0.001). The RCRI and the NSQIP MICA showed no clinical utility before recalibration.

Conclusions: The NSQIP and RCRI models had limited predictive performance in this at-risk population. The recently updated version of the RCRI was more reliable than the original index.

Keywords: cardiac arrest; myocardial infarction; perioperative care; risk assessment; vascular surgical procedures.

Publication types

Evaluation Study

MeSH terms

Aged
Cohort Studies
Death, Sudden, Cardiac / prevention & control
Female
Heart Arrest / etiology*
Heart Arrest / therapy*
Heart Diseases / epidemiology*
Humans
Intraoperative Complications / therapy*
Male
Middle Aged
Models, Statistical
Myocardial Infarction / etiology*
Myocardial Infarction / therapy*
Postoperative Complications / therapy*
Predictive Value of Tests
Quality Improvement
Risk Assessment / standards*
Treatment Outcome
Vascular Surgical Procedures / adverse effects
Vascular Surgical Procedures / methods*