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The Lee index: Risk of perioperative cardiac events [Classics Series]
1. The Lee index is a prospectively validated model that predicts the risk of a cardiac event in patients undergoing noncardiac surgery.
2. The six independent predictors are as follows: 1) high-risk surgery, 2) history of ischemic heart disease, 3) history of congestive heart failure, 4) history of cerebrovascular disease, 5) preoperative treatment with insulin, 6) preoperative serum creatinine >2.0 mg/dL (>177 µmol/L).
Original Date of Publication: September 7, 1999
Study Rundown: Patients undergoing noncardiac surgery are at risk of major cardiovascular complications. With the number of patients undergoing major noncardiac surgery consistently increasing, the incidence of surgery-associated cardiovascular complications has steadily risen. Numerous efforts have been made to identify potential interventions to reduce the likelihood of these complications, with several studies exploring the potential perioperative use of beta-blockers, calcium channel blockers, statins, ASA, and cardiac revascularization.
Several different groups have also attempted to develop tools to stratify patients with regards to their risk of perioperative cardiovascular complications. These include the Kumar, Detsky, and Goldman indices, as well as the American College of Cardiology/American Heart Association algorithm. The Revised Cardiac Risk Index, commonly referred to as the Lee index, was developed by modifying and simplifying the Goldman index. Initially published in 1999, the Lee index is considered the best validated tool for estimating perioperative cardiovascular risk. It uses six equally-weighted criteria to predict the likelihood of a cardiovascular event, and is widely used because of its simplicity.
Click to read the study in Circulation
In-Depth [prospective cohort study]: Of the 4,315 patients that took part in the study, 2,893 were used in the development of the Lee index. The other 1,422 patients took part in the prospective validation cohort. The major cardiovascular complications assessed were myocardial infarction, pulmonary edema, ventricular fibrillation/primary cardiac arrest, or complete heart block. Through logistic regression analyses, six predictors of perioperative major cardiovascular complications were identified: 1) high-risk surgery, 2) ischemic heart disease, 3) history of congestive heart failure, 4) history of cerebrovascular disease, 5) insulin therapy for diabetes, and 6) perioperative serum creatinine >2.0 mg/dL (>177 µmol/L). The presence of any of these predictors contributes 1 point to the Lee index score. Higher Lee index scores were associated with higher rates of perioperative cardiac events.
The Lee index
| Criteria | Points |
| High-risk surgery (e.g., emergency surgery, major thoracic procedures, cardiac procedures, aortic/major vascular procedures, procedures >4 hours) | 1 |
| Ischemic heart disease | 1 |
| History of congestive heart failure | 1 |
| History of cerebrovascular disease | 1 |
| Insulin therapy for diabetes | 1 |
| Perioperative serum creatinine >2.0 mg/dL (>177 µmol/L) | 1 |
Cardiac event rates
| Lee index score | Derivation cohort | Validation cohort |
| 0 | 5/1071 (0.5%) | 2/488 (0.4%) |
| 1 | 14/1106 (1.3%) | 5/567 (0.9%) |
| 2 | 18/506 (3.6%) | 17/258 (6.6%) |
| ≥3 | 19/210 (9.1%) | 12/109 (11.0%) |
Image: PD
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