Using Cardiac Risk Stratification to Guide Medical Decision-making and Informed Consent

There are plenty of validated tools for guiding treatment plans. Organizations need to ensure the ones they’ve chosen are appropriately utilized, assessment results are properly documented, and risk scores are shared with patients engaged in the decision-making process.

Over the past few decades, dozens of patient risk-stratification tools have been developed, tested and proven efficacious for particular types of symptoms, conditions and care settings. In the cardiac patient population, many such evidence-based algorithms are routinely utilized to help providers set appropriate expectations and mitigate risk, if feasible, in order to deliver the best possible clinical outcomes. The tools can prompt discussions with patients about delaying elective surgery until modifiable risks are addressed, or with members of the medical team about approaches to mitigating the risk of a particular complication.

The Society for Thoracic Surgeons (STS) Risk Calculator is the gold standard, used by more than 90 percent of groups that perform cardiac surgery in the U.S. The STS also maintains a cardiac surgery database (established in 1989) that individual facilities can use to benchmark their quality performance against other hospitals around the country, a “like” comparison group and peers in their region. It has been endorsed as a reporting vehicle for individual clinicians under the Centers for Medicare & Medicaid Services Merit-Based Incentive Payment System.

All risk stratification tools work essentially the same way—providers enter known information about a patient, including their family history, and an algorithm calculates the potential for complications (even death) at a future time point if a particular clinical course of action is taken.

Among the patient risk stratification tools available in cardiac care:

  • HEART Risk Calculator – developed by the American College of Cardiology and American Heart Association, it is frequently used by emergency medicine physicians to evaluate chest pain and determine the short-term occurrence of major cardiac events. It is most specific to individuals ages 40 to 79, and simple enough for anyone to complete to learn their cardiac risk factors.
  • STS Risk Calculator – currently used by institutions in over 11 countries, with more than 6.3 million surgeries represented in the databank. The tool estimates a patient’s risk of mortality and other morbidities, such as long length of stay and renal failure, for seven different types of patient procedures (including aortic valve, mitral valve and coronary artery bypass graft [CABG] surgeries). It includes a calculator specific to CABG that calculates the probability of long-term survival among patients 65 years and older.
  • European System for Cardiac Operative Risk Evaluation (EuroSCORE) – European tool, first developed in 1999, widely used in the U.S. to predict 30-day mortality for patients undergoing CABG surgery and inpatient mortality from percutaneous coronary intervention (PCI). It instantly calculates risk by pooling contemporaneous multi-institutional data.
  • SYNTAX Score – Popular U.S. counterpart to EuroSCORE for predicting mortality to guide the choice between PCI and CABG for patients with multivessel coronary disease.
  • Society for Cardiovascular Angiography and Interventions (SCAI) PCI Risk Assessment Tool Pre-procedural patient information gets entered into one calculator to estimate the post-intervention risks for mortality, acute kidney injury (contrast-induced nephropathy) and transfusion for patients who undergo PCI. It’s easy to use and accessible via computer, tablet and smartphone, but relatively young (launched in 2014).
  • Northern New England Cardiovascular Disease Study Group preoperative prediction tools – Validated suite of calculators for predicting morbidity and mortality for CABG surgery, inpatient mortality from mitral surgery and aortic valve replacement, and morbidity (vascular complications, non-fatal myocardial infarction and renal insufficiency) and mortality after PCI.

 New patient risk stratification models are constantly emerging, and existing ones are being updated based on emerging evidence reviewed by professional societies. It’s up to institutions and professional practice groups to determine which ones are of greatest value to their patient populations and utilize as appropriate.

Some organizations are still not using risk stratification tools as consistently as they should be—meaning on every appropriate patient—in part because the algorithms are not always embedded in order sets and processes. Collaborating with the IT department to ensure the latest version of the tools are loaded into the electronic health record is one way to give physicians easy access to them. Most of the tools are also available as apps. Additionally, education for some veteran physicians may be helpful so that they’re aware that risk stratification augments their clinical experience and judgment.

Medical records of any type need a location where clinicians can document risk stratification scores, as they’re every bit as important as information from medical histories, physical exams and physician progress notes. These are not always one-time preoperative scorings. They might also be done postoperatively, or before and after a postponed surgery while the patient works on losing weight, has a sleep apnea study or otherwise gets optimized for the procedure.

An even bigger opportunity than using patient risk stratification tools is sharing the scores with patients, a central feature of patient-centeredness as discussed in my last blog. Sharing risk assessment scores with patients increases their knowledge and engagement in their care and outcomes.

Author Information

Rita Bush

Rita Bush

Rita Bush, RN, MSN, RN, CCRN, NE-BC is a director with HealthTrust’s Clinical Data Solutions. She has extensive experience in hospital-based cardiac nursing and administratively with all aspects of cardiac, critical care and trauma programs. Bush was previously director of nursing for cardiac and medical services at a large teaching and research hospital, and is a co-author on publications related to crisis management and acute care competencies. More Articles by This Author »