Performance of cardiopulmonary exercise testing for the prediction of post-operative complications in non cardiopulmonary surgery: A systematic review

Abstract

Introduction Cardiopulmonary exercise testing (CPET) is widely used within the United Kingdom for preoperative risk stratification. Despite this, CPET's performance in predicting adverse events has not been systematically evaluated within the framework of classifier performance. Methods After prospective registration on PROSPERO (CRD42018095508) we systematically identified studies where CPET was used to aid in the prognostication of mortality, cardiorespiratory complications, and unplanned intensive care unit (ICU) admission in individuals undergoing non-cardiopulmonary surgery. For all included studies we extracted or calculated measures of predictive performance whilst identifying and critiquing predictive models encompassing CPET derived variables. Results We identified 36 studies for qualitative review, from 27 of which measures of classifier performance could be calculated. We found studies to be highly heterogeneous in methodology and quality with high potential for bias and confounding. We found seven studies that presented risk prediction models for outcomes of interest. Of these, only four studies outlined a clear process of model development; assessment of discrimination and calibration were performed in only two and only one study undertook internal validation. No scores were externally validated. Systematically identified and calculated measures of test performance for CPET demonstrated mixed performance. Data was most complete for anaerobic threshold (AT) based predictions: calculated sensitivities ranged from 20-100% when used for predicting risk of mortality with high negative predictive values (96-100%). In contrast, positive predictive value (PPV) was poor (2.9-42.1%). PPV appeared to be generally higher for cardiorespiratory complications, with similar sensitivities. Similar patterns were seen for the PLOS ONE |

Preoperative Cardiopulmonary Exercise Test Associated with Postoperative Outcomes in Patients Undergoing Cancer Surgery: A Systematic Review and Meta-Analyses

“…While there are few systematic reviews indicating a positive association between superior preoperative CPET values and absence of postoperative complications, others reported no significant association. 5 , 7 , 8 , 10 , 11 This is somewhat in line with the results of the current review. Our meta-analysis showed that superior preoperative CPET values are significantly associated with the absence of most postoperative complications.…”

“…Previous systematic reviews included a smaller number of studies (ranging from 7–37), investigated postoperative complications as the main outcome measure, and included either a specific cancer population undergoing surgery (e.g., lung, esophageal), or mixed populations undergoing surgery for cancer and/or noncancer related conditions. 5 , 7 – 11 Meta-analysis was attempted in only half of the previous published systematic reviews. Therefore, the mixed results encountered between the current review and previous reviews may be because the inclusion and exclusion criterion were different.…”

“…While some systematic reviews have reported a significant positive association between preoperative CPET variables and postoperative complications, length of hospital stay, unplanned ICU admission, and 12-months survival, 5 , 7 , 8 others have reported nonsignificant association. 9 – 11 The prospective, multinational cohort (METS) study, for example, demonstrated an association between peak oxygen uptake (peak VO 2 ) and noncardiac complications in a cohort of relatively well patients having noncardiac surgery and not limited to cancer surgery. 12 Some limitations encountered within the previous systematic reviews include the absence of meta-analysis, inclusion of a mixed population (i.e., cancer and noncancer patients), outdated, or focused on a narrow cohort of patients.…”

“… 12 Some limitations encountered within the previous systematic reviews include the absence of meta-analysis, inclusion of a mixed population (i.e., cancer and noncancer patients), outdated, or focused on a narrow cohort of patients. 5 , 7 – 11 Better understanding of the potential association between preoperative CPET variables and postoperative outcomes in cancer patients is extremely important; this can guide preoperative interventions designed to improve patients preoperative physical status. This, in turn, has the potential to reduce postoperative morbidity.…”

Utilizing Machine Learning Techniques to Predict the Efficacy of Aerobic Exercise Intervention on Young Hypertensive Patients Based on Cardiopulmonary Exercise Testing

“…Keller et al suggested that BP overresponse in CPET might be a diagnostic tool for identifying high-risk groups of hypertension [ 21 ]. Besides, CPET can be used as a tool for preoperative risk stratification of patients (not limited to cardiopulmonary surgery) to predict postoperative adverse outcomes [ 22 , 23 ]. Currently, one of the most impressive advances is that the integration of CPET and other tests has been introduced to diagnose several diseases [ 24 ].…”