Revised Cardiac Risk Index (Lee)
Risk of major cardiac complications after elective non-cardiac surgery
Sources last checked: 2026-10-13
Revised Cardiac Risk Index (Lee)
Risk of major cardiac complications after elective non-cardiac surgery
Major cardiac complications 0.4 % in the validation cohort of Lee 1999.
Lee's percentages refer to a 1990s US cohort (age ≥ 50, elective major surgery) and an outcome without routine troponin screening; contemporary recalibrations quoted by ESC 2022 are several times higher. The class transfers better than the percentage.
Interpretation
| Class I (0 factors) | Major cardiac complications 0.4 % in the validation cohort of Lee 1999. |
|---|---|
| Class II (1 factor) | Major cardiac complications 0.9 % in the validation cohort. |
| Class III (2 factors) | Major cardiac complications ≈ 7 % in the validation cohort. |
| Class IV (≥ 3 factors) | Major cardiac complications ≈ 11 % in the validation cohort. |
What is the Revised Cardiac Risk Index (Lee)?
The Revised Cardiac Risk Index counts six clinical factors that predict major cardiac complications after non-cardiac surgery. Lee and colleagues derived it in 1999 from 2 893 patients aged 50 or older undergoing elective major surgery in Boston and validated it in a further 1 422. Each factor scores one point, giving risk classes I–IV.
When to use it
- Preoperative assessment before elective intermediate- or high-risk non-cardiac surgery
- Structuring the clinical risk estimate that ESC 2022 combines with functional capacity and, in selected patients, biomarkers
- Communicating perioperative cardiac risk in a structured, reproducible way
When not to use it
- Cardiac surgery or emergency surgery where assessment would delay treatment
- Patients with active cardiac conditions (acute coronary syndrome, decompensated heart failure, severe valve disease) — the score was not designed for these situations
- As a stand-alone indication for stress testing or revascularisation
How it is calculated
| Criterion | Points |
|---|---|
| High-risk surgery (intraperitoneal, intrathoracic or suprainguinal vascular) | +1 |
| Ischaemic heart disease (prior MI, angina, nitrate use, positive stress test or pathological Q waves) | +1 |
| History of congestive heart failure | +1 |
| History of cerebrovascular disease (stroke or TIA) | +1 |
| Preoperative treatment with insulin | +1 |
| Preoperative creatinine > 2.0 mg/dL (> 177 µmol/L) | +1 |
Clinical pearls and limitations
- Lee's percentages refer to a 1990s US cohort (age ≥ 50, elective major surgery) and an outcome without routine troponin screening; contemporary recalibrations quoted by ESC 2022 are several times higher. The class transfers better than the percentage.
- ESC 2022 lists RCRI among several tools and does not recommend a single score; it combines clinical risk with functional capacity and, in selected patients, troponin and BNP/NT-proBNP.
- Lee's percentages are much lower than modern recalibrated risks (≈ 4–15 % for death, MI or cardiac arrest) because troponin surveillance now detects more events.
- "High-risk surgery" means intraperitoneal, intrathoracic or suprainguinal vascular — not simply "major" surgery.
- The creatinine threshold is > 2.0 mg/dL (≈ 177 µmol/L); eGFR is not part of the original score.
Frequently asked questions
What are the six RCRI criteria?
High-risk surgery, ischaemic heart disease, heart failure, cerebrovascular disease, insulin-treated diabetes and creatinine above 2.0 mg/dL (177 µmol/L). Each adds one point.
Is the RCRI the same as the Lee index?
Yes. Revised Cardiac Risk Index and Lee index refer to the same six-factor score published by Lee et al. in 1999.
What does an RCRI of 2 mean?
Class III: about 7 % major cardiac complications in Lee's validation cohort. Contemporary recalibrations put the risk of death, MI or cardiac arrest nearer 10 %.
Does the ESC guideline require the RCRI?
No. The 2022 ESC guideline (endorsed by ESAIC) describes RCRI and other calculators but chose not to recommend one specific risk score.
Evidence and guidelines
- Primary source: Lee TH 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. Rates: validation cohort as given in the abstract (0.4 %, 0.9 %, 7 %, 11 %).
- Halvorsen S et al. 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery (endorsed by ESAIC). Eur Heart J 2022;43:3826-3924 — discusses RCRI among several risk tools without recommending one specific score; quotes recalibrated risks (≈ 4/6/10/15 % for 30-day death, MI or cardiac arrest).
- Duceppe E et al. Canadian Cardiovascular Society guidelines on perioperative cardiac risk assessment. Can J Cardiol 2017;33:17-32 — source of the recalibrated RCRI risks.
Have a follow-up question?
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Ask Medelix about the Revised Cardiac Risk Index (Lee)Related calculators
- Duke Activity Status Index (DASI)Self-reported functional capacity before surgery, with estimated VO₂peak
- ARISCAT scoreRisk of postoperative pulmonary complications
- eGFR (CKD-EPI 2021)Estimated glomerular filtration rate, race-free equation
- Surgical Apgar ScoreIntraoperative 10-point score for 30-day major complications or death
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