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AUB-HAS2 Cardiovascular Risk Index

Predicts 30-day risk of death, MI, or stroke in patients undergoing non-cardiac surgery

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Why use it

Provides an alternative to RCRI and Gupta MICA for perioperative cardiovascular risk assessment. Specifically developed and validated in a Middle Eastern/Mediterranean population, though applicable broadly. Distinguishes five risk classes with distinct event rates to guide preoperative evaluation, testing, and anesthetic planning.

About

The AUB-HAS2 (American University of Beirut – Heart Attack and Stroke) index is a validated preoperative cardiovascular risk stratification tool for patients undergoing non-cardiac surgery. It predicts the composite 30-day risk of death, non-fatal myocardial infarction, or non-fatal stroke. Developed and validated at the American University of Beirut Medical Center, it incorporates eight clinical variables including history of cardiovascular disease, renal function, surgical procedure type, and functional capacity. It complements the RCRI and Gupta MICA score.

When to use

  • Preoperative cardiovascular risk assessment for any non-cardiac surgical procedure
  • Deciding on need for preoperative cardiac testing or cardiology consultation
  • Complementary to or as an alternative to RCRI in patients where its variables are insufficient
  • Informing shared decision-making discussions about surgical risk with patients

Formula

Score = sum of: Prior CAD (history of MI, revascularization, or stress test-positive): +2 Prior stroke or TIA: +2 Heart failure (current or prior): +1 Diabetes mellitus: +1 Renal insufficiency (Cr > 2.0 mg/dL): +1 High-risk surgery: +1 Poor functional capacity (< 4 METs): +1 Age ≥ 65 years: +1 Class I: 0 | Class II: 1–2 | Class III: 3–4 | Class IV: 5–6 | Class V: ≥ 7

Pearls & pitfalls

  • AUB-HAS2 was validated against actual 30-day MACE events (death + MI + stroke) unlike some other scores.
  • Prior coronary artery disease and prior stroke/TIA each contribute 2 points — the highest weights.
  • Renal insufficiency (Cr > 2.0 mg/dL) is included, mirroring its importance in the RCRI.
  • High-risk surgery (intraperitoneal, intrathoracic, suprainguinal vascular) significantly elevates the score.
  • Poor functional capacity (< 4 METs) reflects patients unable to perform moderate activity without symptoms.
  • The score was derived in a cohort of ~2,000 patients at a single tertiary center — external validation data are more limited than RCRI.

Next steps

Class I (very low risk): Proceed to surgery without additional testing. Class II (low risk): Standard preoperative evaluation; no further cardiac testing required. Class III (moderate risk): Cardiology consultation recommended; consider stress testing if it will change management. Class IV–V (high/very high risk): Comprehensive cardiology evaluation; optimize medical therapy; consider non-invasive stress testing and selective coronary angiography.

Evidence

Dakik HA et al. (Am J Cardiol 2019; J Am Heart Assoc 2020) derived and validated AUB-HAS2 in patients undergoing non-cardiac surgery. Five risk classes with 30-day MACE rates ranging from 0% (Class I) to >15% (Class V). AUC 0.83 for prediction of 30-day MACE.

References

  1. Dakik HA et al. Validation of the AUB-HAS2 cardiovascular risk index for preoperative assessment of patients undergoing non-cardiac surgery. J Am Heart Assoc. 2020;9(5):e014824. — link
  2. Dakik HA et al. A new cardiovascular risk index for patients undergoing non-cardiac surgery. Am J Cardiol. 2019;124(7):1035-1040. — link