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calculator providing an estimate of the absolute 30 day probability of serious complications and any complications compared with the average patient.76 Evaluated in the US surgical database, the ACS NSQIP model performed better than the RCRI, but an external validation in the Philippines found both to have excellent discriminative abilities for predicting any MACE.48 The RCRI can be used without a web connection, whereas the ACS NSQIP is procedure-specific and is only available on the web. For clinical use, the RCRI is more accessible, but the ACS NSQIP offers procedure-specific absolute risk estimates, which are valuable in patient-guided decision-making. In vascular surgery, both risk calculators have shown moderate accuracy with an area under curve (AUC) of 0.64 (95% CI, 0.57–0.70) for ACS NSQIP and 0.60 (95% CI, 0.54–0.65) for RCRI, due to underestimation of the risk of MI. Attempts to generate procedure-specific vascular calculators have not given better predictions in validation cohorts.77 The Surgical Outcome Risk Tool (SORT) estimates 30 day mortality after NCS based on the American Society of Anesthesiologists Physical Status (ASA–PS) grade, urgency of surgery, surgical speciality and severity, cancer, and age ≥65 years. In the validation study, combining subjective assessment with the SORT was significantly better than using either alone.78,79 The Surgical Risk Calculator is another tool that predicts intra-operative and 30 day risk of MI or cardiac arrest based on age, ASA–PS grade, pre-operative dependent functional status, creatinine, and type of surgery.80 The American University of Beirut (AUB)-HAS2 Cardiovascular Risk Index is the most recently developed index to assess 30 day event risk (death, MI, or stroke), and stratifies patients undergoing NCS into low (score 0–1), intermediate (score 2–3), and high risk (score .3) based on six data elements (see Table 6); scores .3 denote a post-operative event rate of .10%.49 The AUB-HAS2 Index has been tested in a broad spectrum of surgical subpopulations and demonstrated superior discriminatory power compared with the commonly utilized RCRI (Table 6).50,51,81 There is significant variability in the predicted risk of cardiac complications using different risk-prediction tools; none can be disqualified with current evidence.82

4.1.2 Frailty

Frailty is an age-related, multidimensional state of decreased physiological reserve that results in diminished resiliency, loss of adaptive capacity, and increased vulnerability to stressors.83,84 The perioperative evaluation of elderly patients (.70 years) who require elective intermediate- or high-risk NCS should include frailty screening, which has proven to be an excellent predictor of unfavourable health outcomes in the older surgical population. Frailty has a relevant impact on mortality and MI risk but does not add to risk estimation derived from the ACS NSQIP calculator, as frailty is associated with variables already in the main model. By adding six variables, the ACS NSQIP predicts the risk of post-operative delirium, functional decline, need of a new mobility aid, or pressure ulcer.85 The use of this broader-inclusive score identifies cases that profit the most by involving a geriatrician in the pre- and postoperative team.86,87 A measure of frailty informs the patient and surgeon about further life expectancy and the chance of post-operative delirium, dependency of mobility support, and need of nursing home or other care support after planned surgery. Of the available screening tools for frailty, the Frailty Index and the Frail Phenotype are the most commonly recommended.88,89 Of note, the Frailty Index includes cognitive testing, while both scores assess physical function.90,91 A simpler approach is offered by the Clinical Frailty Scale, which relies on information from the history taking. The Clinical Frailty Scale has been validated against the Frailty Index.88 For cognitive screening to incorporate with the Frailty Index, Mini-Cog©

is a simple and fast screening tool validated for pre-operative screening92 (Supplementary data, Figure S1, and Tables S2 and S3). Once a diagnosis of frailty is confirmed, the prognosis of a frail patient can be improved by shared decision-making between at least a treating physician (e.g. surgeon), anaesthesiologist, geriatrician, the patient, and the patient’s relatives. During the shared decision-making process, a careful discussion with a frail patient about goals of care could help them to have realistic expectations and make better informed decisions before surgery. After a shared decision to go ahead with a planned NCS, multimodal pre-habilitation programmes—including exercise, nutrition, and psychological interventions—could potentially improve the perioperative prognosis of frail patients by an individualized approach tailored to the patient’s baseline functional status, comorbidities, and cognitive/psychological function.90

4.2 Functional capacity

Quantifying functional capacity has been a pivotal step in preoperative cardiac risk assessment.10 Although the validity of interview-based assessment of functional capacity has been questioned,93 a recent large prospective cohort study of high-risk patients undergoing NCS found self-reported inability to climb two flights of stairs added incremental value to the 30 day cardiac event rate when added to the RCRI.94 Metabolic equivalents (METs) ,4 have long been considered to indicate poor functional capacity; however, studies using METs have been based on subjective interviews and not shown proven value. In the Measurement of Exercise Tolerance before Surgery (METS) study, the Duke Activity Status Index (DASI) (https://www. mdcalc.com/duke-activity-status-index-dasi#evidence) had a more precise estimation of cardiac risk than subjectively assessed functional capacity, improving risk estimation using RCRI.95 A DASI score ,34 was associated with increased odds of 30 day death or MI.96 From the DASI score, METs can be calculated as VO2 max (maximal oxygen consumption)/3.5; where VO2 max (mL/kg/min) = 0.43 × DASI + 9.6. Furthermore, cardiopulmonary exercise testing (CPET) did not predict 30 day mortality, post-operative MI, or cardiac arrest.94,95 It should be noted that a relatively low number of primary outcome events limited the statistical power of the analysis.

Recommendation Table 6 — Recommendations for pre-operative assessment of frailty and functional capacity

Recommendations Classa Levelb

In patients aged ≥70 years and scheduled to undergo intermediate- or high-risk NCS, frailty screening should be considered using a validated screening tool.84–87,90,91 IIa B

Continued

ESC Guidelines                                                                                                                                                                                     3849

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