The Revised Cardiac Risk Index Delivers What It Promised

Annals of internal medicine (Impact Factor: 17.81). 01/2010; 152(1):57-8. DOI: 10.1059/0003-4819-152-1-201001050-00013
Source: PubMed
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    • "While contemporary surgical researchers had already employed multivariate statistical methods to examine mortality among patients with a particular operative illness (Irvin and Zeppa 1976), Goldman's index predicted the occurrence of any one of several potential negative outcomes, all linked to the dysfunction of a single organ system, across a range of surgical procedures. And while cardiac events had been recognized in Goldman's time to be a principal contributor to surgical morbidity and mortality (Arkins, Smessaert, and Hicks 1964; Tarhan et al. 1972), the " precise determination " promised by Goldman's approach was limited to the extent that it did not predict a range of other key end points, such as noncardiac complications or all-cause mortality, relevant to operative risk assessment (Goldman 2010). In contrast to the apparent " guesswork " implicit in earlier approaches to risk assessment, Goldman's index promised a precise, numerical estimate of risk but did so for only a selected set of complications, described in the 1981 edition of the Textbook of Surgery as " fatal and nonfatal, but life-threatening, complications of cardiac origin " (Polk 1981, 123). "
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    ABSTRACT: Current efforts to improve the cost-effectiveness of health care focus on assessing accurately the value of technologically complex, costly medical treatments for individual patients and society. These efforts universally acknowledge that the determination of such value should incorporate information regarding the risks posed by a given treatment for an individual, but they typically overlook the implications for medical decision making that inhere in how notions of risk are understood and used in contemporary medical discourse. To gain perspective on how the hazards of surgery have been defined and redefined in medical thought, we examine changes over time in notions of risk related to operative care. We reviewed historical writings on risk assessment and patient selection for surgical procedures published between 1957 and 1997 and conducted informal interviews with experts. To examine changes attributable to advances in research on risk assessment, we focused on the period surrounding the 1977 publication of an influential surgical risk-stratification index. Writings before 1977 demonstrate a summative, global approach to patients as "good" or "poor" risks, without quantifying the likelihood of specific postoperative events. Beginning in the early 1980s, assessments of operative risk increasingly emphasized quantitative estimates of the probability of dysfunction of a specific organ system after surgery. This new approach to establishing surgical risk was consistent with concurrent trends in other domains of medicine. In particular, it emphasized a more "scientific," standardized approach to medical decision making over an earlier focus on individual physicians' judgment and professional authority. Recent writings on operative risk reflect a viewpoint that is more specific and, at the same time, more generic and fragmented than earlier approaches. By permitting the separation of multiple component hazards implicit in surgical interventions, such a viewpoint may encourage a distinct, permissive standard for surgical interventions that conflicts with larger policy efforts to promote cost-effective decision making by physicians and patients.
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    ABSTRACT: Cardiovascular risk prediction using clinical risk factors is integral to both the European and the American algorithms for preoperative cardiac risk assessment and perioperative management for non-cardiac surgery. We have reviewed these risk factors and their ability to guide clinical decision making. We examine their limitations and attempt to identify factors which may improve their performance when used for clinical risk stratification. To improve the performance of the clinical risk factors, it is necessary to create uniformity in the definitions of both cardiovascular outcomes and the clinical risk factors. The risk factors selected should reflect the degree of organ dysfunction rather than a historical diagnosis. Parsimonious model design should be applied, making use of a minimal number of continuous variables rather than creating overfitted models. The inclusion of age in the model may assist partly in controlling for the duration of risk factor exposure. Risk assignment should occur throughout the perioperative period and the risk factors chosen for model inclusion should vary depending on when the assignment occurs (before operation, intraoperatively, or after operation).
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