What is the Revised Cardiac Risk Index?

The RCRI (Lee Criteria), published by Lee et al. in 1999 (Circulation), is a 6-predictor clinical scoring system that stratifies perioperative cardiac risk for major non-cardiac surgery into Classes I through IV.

What are the canonical RCRI / Lee classes?

Score 0 corresponds to Class I (Low Risk); Score 1 to Class II (Low Risk); Score 2 to Class III (Intermediate Risk); and Scores 3 to 6 to Class IV (High Risk).

What surgeries does the RCRI apply to?

It applies to adult non-cardiac surgeries (orthopedic, abdominal, vascular, thoracic, urological, etc.). It is not derived or validated for cardiac surgery or minor ambulatory procedures (e.g., superficial dermatologic or cataract procedures).

What qualifies as high-risk surgery under RCRI?

High-risk surgical procedures include suprainguinal vascular, intrathoracic, or intraperitoneal procedures.

What is the 2024 AHA/ACC guideline threshold?

The 2024 AHA/ACC perioperative guideline treats RCRI > 1 (scores 2 through 6) as elevated risk. It lists the RCRI among several validated risk tools rather than requiring one, and pairs the estimate with functional capacity: patients at elevated risk with poor or unknown capacity (under 4 METs) may need further evaluation if it would change management.

What is the risk percentage for each RCRI score?

In Lee 1999 major cardiac complication rates for 0, 1, 2 and 3 or more points were 0.5%, 1.3%, 3.6% and 9.1% in the derivation cohort (2,893 patients) and 0.4%, 0.9%, 6.6% and 11.0% in the validation cohort (1,422 patients). Those rates relied on CK-MB and excluded death, so the 2017 Canadian Cardiovascular Society guideline pooled newer troponin-era studies: 30-day risk of MI, cardiac arrest or death is 3.9% (95% CI 2.8–5.4), 6.0% (4.9–7.4), 10.1% (8.1–12.6) and 15.0% (11.1–20.0).

Who was the RCRI derived in?

Lee et al. studied 4,315 patients aged 50 or older having elective major non-cardiac surgery with an expected stay of at least 2 days at one Boston hospital from 1989 to 1994. Emergency surgery was excluded, so the score may underestimate risk in emergency, vascular and frail patients.

What creatinine counts for the RCRI?

A preoperative serum creatinine above 2.0 mg/dL, which is above 176.8 µmol/L (often rounded to 177). Enter a creatinine value in either unit and the calculator ticks the criterion when it is above that threshold.

What do the 2017 Canadian guidelines recommend after the RCRI?

The CCS 2017 guideline suggests measuring BNP or NT-proBNP before surgery in patients aged 65 or older, aged 45 to 64 with significant cardiovascular disease, or with an RCRI score of 1 or more, and daily troponin for 48 to 72 hours after surgery when the natriuretic peptide is elevated or was not measured. It recommends against routine preoperative stress testing.

Revised Cardiac Risk Index

Add one point for each of the six Lee criteria to get the 0–6 RCRI score, Lee Class I–IV and the estimated 30-day risk of MI, cardiac arrest or death (3.9% at 0 points to 15% at 3 or more).

The RCRI adds 1 point each for high-risk surgery, ischemic heart disease, heart failure, cerebrovascular disease, insulin-treated diabetes and creatinine above 2.0 mg/dL.

Six Clinical Criteria

1 pt each

Select each validated predictor present preoperatively.

High-Risk Surgery Suprainguinal vascular, intraperitoneal, or intrathoracic procedure

History of Ischemic Heart Disease Prior MI, positive stress test, angina, nitrate therapy, or pathologic Q waves

History of Congestive Heart Failure Prior pulmonary edema, PND, bilateral rales, S3 gallop, or clinical heart failure

History of Cerebrovascular Disease Prior transient ischemic attack (TIA) or stroke

Preoperative Insulin Therapy Diabetes mellitus currently treated with preoperative insulin

Preoperative Creatinine > 2.0 mg/dL Baseline serum creatinine > 2.0 mg/dL (> 177 µmol/L)

Creatinine (optional)

Age (optional)

Perioperative Risk Assessment

RCRI Score (0–6)

Class I

Low Risk

Score Progression (0–6) Below traditional elevated threshold

Score 0 Score >1 (Elevated) Score 6

30-day MI, arrest or death

3.9%

95% CI 2.8–5.4% · CCS 2017 pooled estimate

Lee 1999 major cardiac complications

0.4%

Validation cohort · derivation 0.5%

0 of 6 predictors selected

Canonical RCRI (Lee) Stratification AHA/ACC Framework

Class	Score	Risk Tier	Lee 1999 (deriv. / valid.)	CCS 2017, 30-day	2024 AHA/ACC Threshold
Class I	0	Low	0.5% / 0.4%	3.9% (2.8–5.4)	Below traditional elevated threshold
Class II	1	Low	1.3% / 0.9%	6.0% (4.9–7.4)	Below traditional elevated threshold
Class III	2	Intermediate	3.6% / 6.6%	10.1% (8.1–12.6)	Elevated calculated risk marker
Class IV	3–6	High	9.1% / 11.0%	15.0% (11.1–20.0)	Elevated calculated risk marker

Clinical Guidance & Limitations

RCRI Class I (Score 0). Below the traditional elevated-risk cutoff. Integrate with symptoms, functional capacity, surgical urgency, and clinician judgment.

Primary composite endpoint: Myocardial infarction, pulmonary edema, ventricular fibrillation/primary cardiac arrest, and complete heart block (Lee et al. 1999).

Risk estimates: Lee 1999 rates (CK-MB era, no deaths counted) are much lower than the CCS 2017 pooled 30-day estimates (Duceppe et al., Can J Cardiol 2017), which add death and troponin-detected MI. Both are group averages, not a single-patient probability.

Not medical advice. This calculator supports, and does not replace, assessment by the treating clinicians.

Scope: Decision-support tool for adult non-cardiac surgery. It does not replace individualized multidisciplinary assessment or mandate surgical postponement.

Quick answer

The RCRI adds 1 point each for high-risk surgery, ischemic heart disease, heart failure, cerebrovascular disease, insulin-treated diabetes and creatinine above 2.0 mg/dL. Updated 2017 CCS estimates of 30-day MI, cardiac arrest or death are 3.9% for 0 points, 6.0% for 1, 10.1% for 2 and 15.0% for 3 or more; a score above 1 is the traditional elevated-risk marker.

Examples

RCRI score	Lee class	Lee 1999 (validation)	CCS 2017, 30-day
0	I	0.4%	3.9%
1	II	0.9%	6.0%
2	III	6.6%	10.1%
3 or more	IV	11.0%	15.0%

Tick the criteria that apply to see the score, class, risk estimates and a copyable note.

Summary

The Revised Cardiac Risk Index (RCRI), derived and validated by Lee et al. in 1999, sums six equally weighted clinical predictors before major non-cardiac surgery to stratify patients into Classes I through IV. Its original composite cardiac outcome included myocardial infarction, pulmonary edema, ventricular fibrillation or primary cardiac arrest, and complete heart block. The 2024 AHA/ACC guideline traditionally identifies an RCRI score greater than 1 as an elevated calculated risk marker. The score provides structured decision support and must be integrated with functional capacity, surgical urgency, and patient factors.

How it works

Review the six independent Lee criteria and select each that applies to the patient.
The calculator sums one point per criterion for a total score of 0 to 6.
Scores map directly to canonical Lee Classes: Class I (0), Class II (1), Class III (2), and Class IV (3–6).
Scores above 1 (>1) reach the traditional 2024 AHA/ACC threshold for elevated calculated perioperative risk.
The risk panel shows the Lee 1999 complication rates and the 2017 Canadian Cardiovascular Society pooled 30-day estimate for the same score, which uses troponin-era studies and includes death.
Optionally enter creatinine in mg/dL or µmol/L to tick the renal criterion automatically, and age to see the CCS 2017 BNP/NT-proBNP screening suggestion.
Click Copy Clinical Summary to generate a formatted perioperative note for the health record.

Use cases

Preoperative cardiac risk stratification before elective non-cardiac surgery.
Determining whether a patient meets the traditional RCRI > 1 elevated calculated risk threshold.
Standardizing perioperative documentation in EHR pre-anesthetic and surgical consult notes.
Facilitating multidisciplinary discussion among surgeons, anesthesiologists, and cardiologists.
Bedside risk assessment in preoperative holding areas and surgical pre-assessment clinics.

Frequently Asked Questions

Last updated: 2026-10-09 · Reviewed by Nham Vu