Before surgery, explained
Revised Cardiac Risk Index (RCRI) calculator
The Revised Cardiac Risk Index, also called the Lee index, is a 6-item score that surgical and anesthesia teams use to gauge the chance of a major heart complication around major noncardiac surgery. This page lets you see how the score works and what the original study found. It is context for a talk with your care team, not a clearance for surgery.
Which of these apply?
6 yes/no factors. Ask your surgical team if you are unsure about one. Nothing you choose leaves this page.
What you will see
The RCRI score out of 6, its class (I to IV) and the rate of major heart complications the 1999 study found for that number of factors.
Educational only, not medical advice. Not a clearance for surgery; your surgical and anesthesia team decides.
Source
Lee TH et al., Circulation 1999. The 6 factors and the complication rates by number of factors are as printed in that paper's abstract; the definition of each factor is as reprinted in Table 1 of Johnson EP et al., Clinical Practice 2024.
Validated in
4315 patients aged 50 or older having elective major noncardiac surgery at one tertiary-care teaching hospital: 2893 in the derivation group and 1422 in the validation group.
Limits
Made for stable patients having nonurgent major noncardiac surgery, not emergency surgery or heart surgery. It does not predict well for vascular surgery such as aortic aneurysm repair, and later studies found it can underestimate the actual rate of heart complications. It is one input for the care team, not a clearance for surgery and not a test for heart disease.
How the RCRI is scored
Each factor that applies adds 1 point, so the score runs from 0 to 6 (Lee 1999) (Moraes 2022). The 6 factors are a high-risk type of surgery, a history of ischemic heart disease, a history of congestive heart failure, a history of cerebrovascular disease, treatment with insulin before surgery, and a serum creatinine above 2.0 mg/dL before surgery (Lee 1999). High-risk surgery means intraperitoneal, intrathoracic or suprainguinal vascular surgery (Johnson 2024).
The study counted major cardiac complications: heart attack, fluid on the lungs (pulmonary edema), ventricular fibrillation or cardiac arrest, and complete heart block (Moraes 2022). The rates it found were:
| Factors present | Class | Derivation group | Validation group |
|---|---|---|---|
| 0 | I | 0.5% | 0.4% |
| 1 | II | 1.3% | 0.9% |
| 2 | III | 4% | 7% |
| 3 or more | IV | 9% | 11% |
Rates as printed in the study abstract (Lee 1999). Reviews label 0, 1, 2 and 3 or more factors as classes I to IV (Moraes 2022).
How well it works
In the 1999 validation group, the RCRI separated patients with and without complications better than the other published indexes it was compared with (Lee 1999). Across later validation studies, its pooled area under the curve (AUC) was 0.75 (Duncan 2016); AUC runs from 0.5 (no better than chance) to 1.0 (perfect). A review notes that it is less accurate at giving an individual's absolute risk, that in 2 validation studies it underestimated the actual event rate by 6 to 7 times, and that it performed poorly in vascular surgery, especially aortic aneurysm repair (Duncan 2016).
What this score is for
The study authors describe the index as a way to find patients at higher risk who may need further testing or other management, and low-risk patients in whom more testing is unlikely to help (Lee 1999). Your surgical and anesthesia team weighs it together with your symptoms, how active you are, the exact operation and other tests. A low score does not mean surgery is safe for you, and a high score does not mean you cannot have surgery. If you have questions about your heart before an operation, ask the team planning it.
Related tools
For your long-term heart risk outside of surgery, see the heart risk calculator (AHA PREVENT). If you have high blood pressure, coronary heart disease or valve disease, the heart failure risk calculator uses the Framingham heart failure profile. Asked how active you are before surgery? The Duke Activity Status Index calculator turns 12 everyday activities into a score and estimated METs.
Sources
- Lee TH, Marcantonio ER, Mangione CM, Thomas EJ, Polanczyk CA, Cook EF, Sugarbaker DJ, Donaldson MC, Poss R, Ho KK, Ludwig LE, Pedan A, Goldman L. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. 1999;100(10):1043-1049. doi:10.1161/01.cir.100.10.1043. PMID 10477528. (Origin of the Revised Cardiac Risk Index; its abstract prints the 6 factors, the cohorts and the complication rates for 0, 1, 2 and 3 or more factors. We read the abstract.) pubmed.ncbi.nlm.nih.gov/10477528/
- Johnson EP, Monsour R, Hafez O, Kotha R, et al. Major Perioperative Cardiac Risk Assessment: A Review for Cardio-Oncologists and Perioperative Physicians. Clin Pract. 2024;14(3):906-914. doi:10.3390/clinpract14030071. PMC11130950. (Table 1 reprints the definition of each RCRI factor, citing Lee 1999.) pmc.ncbi.nlm.nih.gov/articles/PMC11130950/
- Moraes CMT, Corrêa LM, Procópio RJ, Carmo GALD, et al. Tools and scores for general and cardiovascular perioperative risk assessment: a narrative review. Rev Col Bras Cir. 2022;49:e20223124. doi:10.1590/0100-6991e-20223124. PMC10578796. (Describes the RCRI outcome, the 1-point scoring and classes I to IV, citing Lee 1999.) pmc.ncbi.nlm.nih.gov/articles/PMC10578796/
- Duncan D, Wijeysundera DN. Preoperative Cardiac Evaluation and Management of the Patient Undergoing Major Vascular Surgery. Int Anesthesiol Clin. 2016;54(2):1-32. doi:10.1097/AIA.0000000000000091. PMC5087846. (Reviews how the RCRI performed in later validation studies and its limits.) pmc.ncbi.nlm.nih.gov/articles/PMC5087846/
Written and maintained by the uncovermyrisk.com editorial team. We do not have a medical reviewer; every claim links to its primary source above. Last reviewed: 2026-11-01. Spotted an error? See About.