Perioperative
Pre-Op Risk Calculator (RCRI) & QuickNote
A guided workflow for perioperative risk assessment with copy-ready documentation.
This tool is a clinical aid and does not replace clinical judgement. Verify all recommendations with patient-specific factors.
Procedure Risk and Urgency
These choices set the starting branch of the guideline.
Created and maintained by Yasmine Abbey, MD, MSc · Last reviewed:
Educational decision-support for clinicians. Not medical advice — verify all outputs against your clinical judgment, institutional protocols, and current guidelines.
How this pre-op risk calculator works
Preoperative medical evaluation — what surgeons call 'pre-op clearance' or 'surgical clearance' — is not a yes-or-no verdict. It is a structured estimate of perioperative cardiac risk, a decision about whether any test would change management, and a plan for the patient's medications around surgery. This tool walks through that sequence the way the ACC/AHA perioperative guideline lays it out, then assembles the result into a consult note you can edit and paste into the chart.
You enter the procedure risk and urgency, any active cardiac conditions, the six Revised Cardiac Risk Index (RCRI) predictors, functional capacity, home medications including anticoagulants and antiplatelets, prior revascularization, and relevant labs. The calculator returns the RCRI class with its approximate event rate, flags conditions that should delay elective surgery, drafts medication instructions, and — optionally — asks an AI model to add perioperative plans for the extra problems you note (cirrhosis, chronic steroids, opioid use, infection), always anchored to the facts you entered.
Step 1 — Urgency and active cardiac conditions come first
Emergency surgery proceeds with risk mitigation rather than risk stratification; the workup should never delay a life- or limb-saving operation. For elective and time-sensitive cases, the first question is whether an active cardiac condition is present: an acute coronary syndrome or unstable angina, a recent myocardial infarction (within 60 days), decompensated heart failure, a significant arrhythmia, advanced AV block, or severe symptomatic valvular disease. Any of these calls for evaluation and treatment before elective surgery, and the tool says so explicitly in the note rather than proceeding to a risk score.
Step 2 — The RCRI score and what the percentages mean
The Revised Cardiac Risk Index (Lee, 1999) is the most widely used preoperative cardiac risk calculator: one point each for high-risk surgery (intraperitoneal, intrathoracic, or suprainguinal vascular), ischemic heart disease, heart failure, cerebrovascular disease, insulin-treated diabetes, and a creatinine above 2.0 mg/dL. The tool maps the total to the approximate rate of major adverse cardiac events used in the ACC/AHA guideline: about 0.4% for 0 points, 1.0% for 1 point, 2.4% for 2 points, and 5.4% or more for 3 or more points.
RCRI is deliberately simple, which is why it travels well, but it was derived before modern perioperative care and it under-predicts risk for vascular surgery and over-predicts for some low-risk procedures. When you need a procedure-specific estimate, the NSQIP surgical risk calculator (CPT-specific) or the Gupta myocardial infarction and cardiac arrest (MICA) model are the complements; the note leaves a field to record a NSQIP estimate alongside the RCRI.
Step 3 — Functional capacity: METs, two flights of stairs, and the DASI
If the patient is at elevated risk (RCRI of 1 or more, or a higher-risk procedure), the next question is functional capacity. A patient who can climb two flights of stairs or walk up a hill without stopping is performing roughly 4 metabolic equivalents (METs) or more, and in that case further cardiac testing rarely changes management. The Duke Activity Status Index (DASI) is a validated questionnaire that estimates METs more reliably than a clinician's impression; the METS study (Wijeysundera, 2018) found that subjective assessment performed poorly while the DASI predicted outcomes, so the tool accepts a DASI score when you have one.
Below 4 METs, or when capacity is unknown, the guideline allows pharmacologic stress testing only if the result would change the decision to operate or the perioperative plan. A resting echocardiogram is reasonable for suspected or worsening valvular disease or unexplained dyspnea, and a preoperative ECG is reasonable in patients with known cardiovascular disease undergoing elevated-risk surgery. Routine testing in low-risk patients or before low-risk procedures is not recommended.
Step 4 — Medications: continue, hold, or start
- Beta-blockers: continue a home beta-blocker; do not start one on the day of surgery. If newly indicated, start at least a week beforehand and titrate to heart rate and blood pressure.
- Statins: continue; start in patients undergoing vascular surgery or with another indication.
- SGLT2 inhibitors: hold 3 to 4 days before surgery (ertugliflozin 4 days) to reduce the risk of euglycemic ketoacidosis.
- ACE inhibitors and ARBs: holding on the morning of surgery is reasonable for most elective cases; resume once euvolemic and hemodynamically stable.
- Warfarin: usually stopped about 5 days before surgery with an INR check; bridging with heparin is reserved for very high thrombotic risk (recent VTE, mechanical mitral valve, prior stroke with atrial fibrillation) and is decided with surgery and anesthesia.
- DOACs (apixaban, rivaroxaban, edoxaban, dabigatran): hold 1 to 2 days for low-bleeding-risk procedures and 2 to 4 days for high-bleeding-risk procedures, longer with renal impairment, especially for dabigatran. No bridging.
- Antiplatelets: continue aspirin when there is a coronary stent or recent event unless the surgeon objects; elective surgery is deferred for at least 30 days after a bare-metal stent and ideally 6 months after a drug-eluting stent, with a P2Y12 inhibitor stopped 5 to 7 days beforehand when it must be held.
Beyond the heart: the problems the note adds
Cardiac risk is the core of the evaluation, but it is rarely the whole consult. The tool lets you flag bleeding risk, an active infection, chronic steroid use (stress-dose steroids), cirrhosis (with a VOCAL-Penn estimate if you have one), alcohol use (withdrawal precautions, thiamine before glucose), and chronic opioid use or medication-assisted treatment (continue baseline therapy, plan multimodal analgesia). When you add a one-line history — 'HTN, CKD, insulin-dependent diabetes' — the AI step turns each into its own problem heading with one to three perioperative bullets, using only the facts you entered. It never invents labs or diagnoses, and the note stays yours to edit.
What this tool does not do
It does not 'clear' a patient. It documents risk and a plan so that the surgical and anesthesia teams can make an informed decision with the patient. It does not replace a procedure-specific calculator when one is needed, does not estimate pulmonary or frailty risk, and does not account for institutional protocols that may differ from the guideline defaults above. Every recommendation should be checked against the patient in front of you.
Frequently asked questions
What is pre-op clearance, and is 'clearance' the right word?
Pre-op (surgical) clearance is the common name for a preoperative medical evaluation: an estimate of perioperative risk, a decision about whether any test would change management, and a medication plan for the days around surgery. Guidelines discourage the word 'clearance' because no evaluation makes surgery risk-free; the consult documents risk and optimization, and the surgical team decides with the patient. This calculator produces that documentation.
How is the RCRI score calculated?
One point each for: high-risk surgery (intraperitoneal, intrathoracic, or suprainguinal vascular), a history of ischemic heart disease, a history of heart failure, a history of cerebrovascular disease (stroke or TIA), insulin-treated diabetes, and a preoperative creatinine above 2.0 mg/dL. Approximate rates of major adverse cardiac events are 0.4% for 0 points, 1.0% for 1, 2.4% for 2, and 5.4% or more for 3 or more. The calculator adds the points and shows the rate in the note.
What is the difference between the RCRI and the Goldman cardiac risk index?
The Goldman index (1977) was the original multivariable cardiac risk score for noncardiac surgery, with nine weighted factors. The Revised Cardiac Risk Index (Lee, 1999) simplified it to six equally weighted predictors and is the version used in current guidelines and in this calculator. Searches for a 'Goldman risk index calculator' almost always mean the RCRI in practice.
What is a METs score for pre-op assessment?
METs (metabolic equivalents) describe functional capacity. Four METs — climbing two flights of stairs, walking up a hill, or brisk walking on level ground — is the threshold used in the perioperative guidelines: at 4 METs or more, further cardiac testing rarely changes management. Because clinician estimates of METs are unreliable, the Duke Activity Status Index (DASI) questionnaire is preferred; a DASI score of about 34 corresponds to 4 METs. The tool accepts either the two-flights answer or a DASI score.
When does a patient need a stress test or echocardiogram before surgery?
Only when the result would change management. The ACC/AHA guideline supports pharmacologic stress testing for patients at elevated risk with poor or unknown functional capacity if it will alter the decision to operate or the perioperative plan, and a resting echocardiogram for suspected or worsening valvular disease, unexplained dyspnea, or heart failure with a change in clinical status. Routine testing before low-risk surgery, or in patients who can do 4 METs, is not recommended.
Should beta-blockers be started before surgery?
Continue a beta-blocker the patient already takes. Do not start one on the day of surgery: the POISE trial showed that same-day high-dose metoprolol reduced myocardial infarction but increased stroke and death. If a beta-blocker is newly indicated, start it at least 7 days before surgery and titrate to heart rate and blood pressure.
How long should a DOAC be held before surgery, and is bridging needed?
For apixaban, rivaroxaban, and edoxaban: hold 1 day before a low-bleeding-risk procedure and 2 days before a high-bleeding-risk procedure (the PAUSE protocol); for dabigatran, extend to 2 and 4 days with reduced kidney function. Bridging with heparin is not used for DOACs. Warfarin is different: it is usually stopped 5 days before surgery, and bridging is reserved for patients at very high thrombotic risk.
What should happen with SGLT2 inhibitors and insulin before surgery?
Hold SGLT2 inhibitors 3 days before surgery (4 days for ertugliflozin) to reduce the risk of euglycemic diabetic ketoacidosis, and resume once the patient is eating and drinking normally. For insulin-treated patients who will be NPO, reduce the basal dose (commonly by about 20 to 25% the evening before and the morning of surgery), hold prandial insulin while NPO, and check glucose before and during surgery.
Is there a pre-op mortality calculator?
The RCRI estimates major cardiac events, not death. For procedure-specific mortality and complication risk, use the ACS NSQIP surgical risk calculator, which needs the planned CPT code and patient factors; the Gupta MICA model estimates perioperative myocardial infarction or cardiac arrest. This tool leaves a field for a NSQIP estimate so both numbers appear in the same note.
Can this tool do a pre-op risk assessment for older adults or patients with cirrhosis?
Partly. For older adults, the guideline recommends assessing frailty and cognition in addition to cardiac risk; the tool's additional-notes field lets you document those findings but does not score them. For cirrhosis, the VOCAL-Penn score estimates postoperative mortality better than MELD or Child-Pugh; enter its result and the tool carries it into the note.
References
- Thompson A, Fleischmann KE, Smilowitz NR, et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline for perioperative cardiovascular management for noncardiac surgery. Circulation. 2024;150(19):e351–e442.
- Lee TH, Marcantonio ER, Mangione CM, 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.
- Wijeysundera DN, Pearse RM, Shulman MA, et al. Assessment of functional capacity before major non-cardiac surgery: an international, prospective cohort study (METS). Lancet. 2018;391(10140):2631–2640.
- Gupta PK, Gupta H, Sundaram A, et al. Development and validation of a risk calculator for prediction of cardiac risk after surgery. Circulation. 2011;124(4):381–387.
- Douketis JD, Spyropoulos AC, Duncan J, et al. Perioperative management of patients with atrial fibrillation receiving a direct oral anticoagulant (PAUSE). JAMA Intern Med. 2019;179(11):1469–1478.
- POISE Study Group. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial). Lancet. 2008;371(9627):1839–1847.
- Mahmud N, Fricker Z, Hubbard RA, et al. Risk prediction models for post-operative mortality in patients with cirrhosis (VOCAL-Penn). Hepatology. 2021;73(1):204–218.