Using the 6-minute walk test to predict disability-free survival after major surgery

Shulman, Mark; Cuthbertson, Brian H.; Wijeysundera, Duminda N.; Pearse, Rupert M.; Torres, Elizabeth; Ambosta, A.; Farrington, C.; Myles, Paul S.; Wallace, Sophie; Thompson, Bruce; Ellis, Mathew J.; Borg, B.; Kerridge, Ross; Douglas, Jeanene; Brannan, John D.; Pretto, J.; Godsall, M.G.; Beauchamp, N.; Allen, Sandra L.; Kennedy, A.; Wright, E.; Malherbe, J.; Ismail, Hilmy; Riedel, Bernhard; Melville, Andrew; Sivakumar, H.; Murmane, A.; Kenchington, K.; Gurunathan, Usha; Stonell, C.; Brunello, K.; Steele, Katherine T.; Tronstad, Oystein; Masel, P.; Dent, Annette; Smith, Emma L.; Bodger, A.; Abolfathi, M.; Sivalingam, P; Hall, Adrian; Painter, Thomas; Macklin, S.; Elliott, Adrian D.; Carrera, Anna; Terblanche, N; Pitt, S.; Samuels, Jason M.; Wilde, C.; MacCormick, Andrew; Leslie, Kate; Bramley, David E.; Southcott, Anne Marie; Grant, J. C. Boileau; Taylor, H.; Bates, Samantha; Towns, Miriam; Tippett, A.; Marshall, Fiona; McCartney, Colin J. L.; Choi, Stephen; Somascanthan, Priya; Flores, K.; Beattie, W. Scott; Karkouti, Keyvan; Clarke, Hance; Jerath, Angela; McCluskey, Stuart A.; Wąsowicz, Marcin; Granton, John; Day, Lauren; Pazmino‐Canizares, Janneth; Hagen, K.; Campbell, Douglas; Short, Tim; Westhuizen, J. Van Der; Higgie, Kushlin; Lindsay, Helen; Jang, R.; Wong, Chris Ho Ming; McAllister, Davina; Ali, M; Kumar, J.; Waymouth, Ellen; Kim, C.; Dimech, J.; Lorimer, Michael; Tai, Joyce; Miller, Reuben Jonathan; Sara, R.; Collingwood, A.; Olliff, Sue; Gabriel, S.; Houston, Helen; Dalley, Paul; Hurford, Sally; Hunt, Anna; Andrews, Lynn; Navarra, Leanlove; Jason-Smith, A.; Thompson, Helen; McMillan, N.; Back, G.; Melo, Magda; Mamdani, Muhammad; Hillis, Graham S.; Wijeysundera, Harindra C.

doi:10.1016/j.bja.2018.08.016

Cited by 49 publications

(39 citation statements)

References 25 publications

(19 reference statements)

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“…25,26 As part of a pre-specified substudy on the prognostic performance of the 6 min walk test, the WHODAS questionnaire was administered before surgery and subsequently at 1 yr post-surgery. 27 The questionnaire consists of 12 items, each of which is scored 0e4. The sum of all item responses is the WHODAS disability score, which ranges from 0 to 40 and can be expressed as a Table 1 Characteristics of the study sample.…”

Section: Subset Analysis On New Postoperative Disabilitymentioning

confidence: 99%

Integration of the Duke Activity Status Index into preoperative risk evaluation: a multicentre prospective cohort study

Wijeysundera

Beattie

Abbott

et al. 2020

British Journal of Anaesthesia

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Background: The Duke Activity Status Index (DASI) questionnaire might help incorporate self-reported functional capacity into preoperative risk assessment. Nonetheless, prognostically important thresholds in DASI scores remain unclear. We conducted a nested cohort analysis of the Measurement of Exercise Tolerance before Surgery (METS) study to characterise the association of preoperative DASI scores with postoperative death or complications. Methods: The analysis included 1546 participants (!40 yr of age) at an elevated cardiac risk who had inpatient noncardiac surgery. The primary outcome was 30-day death or myocardial injury. The secondary outcomes were 30-day death or myocardial infarction, in-hospital moderate-to-severe complications, and 1 yr death or new disability. Multivariable logistic regression modelling was used to characterise the adjusted association of preoperative DASI scores with outcomes. Results: The DASI score had non-linear associations with outcomes. Self-reported functional capacity better than a DASI score of 34 was associated with reduced odds of 30-day death or myocardial injury (odds ratio: 0.97 per 1 point increase above 34; 95% confidence interval [CI]: 0.96e0.99) and 1 yr death or new disability (odds ratio: 0.96 per 1 point increase above 34; 95% CI: 0.92e0.99). Self-reported functional capacity worse than a DASI score of 34 was associated with increased odds of 30-day death or myocardial infarction (odds ratio: 1.05 per 1 point decrease below 34; 95% CI: 1.00e1.09), and moderate-to-severe complications (odds ratio: 1.03 per 1 point decrease below 34; 95% CI: 1.01e1.05). Conclusions: A DASI score of 34 represents a threshold for identifying patients at risk for myocardial injury, myocardial infarction, moderate-to-severe complications, and new disability.

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Section: Subset Analysis On New Postoperative Disabilitymentioning

confidence: 99%

Integration of the Duke Activity Status Index into preoperative risk evaluation: a multicentre prospective cohort study

Wijeysundera

Beattie

Abbott

et al. 2020

British Journal of Anaesthesia

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“…Several studies have determined the relation between the 6MWT and postoperative (cardiac) complications and mortality. 23,[26][27][28] Those studies showed conflicting results but overall no good relation between the 6MWT and postoperative complications. 25 However, some more recent studies showed a good relation between a low 6MWT and cardiopulmonary complications.…”

Section: The Literaturementioning

confidence: 99%

“…26,27 Finally, a recent study by Shulman and colleagues in patients undergoing major surgery showed that the 6MWT was predictive of death and myocardial infarction. 28 Gait speed is another test for functional capacity and is used in elderly patients in the assessment of frailty. 29 There is a relation between low gait speed and increased mortality in elderly patients undergoing cardiac surgery.…”

Section: The Literaturementioning

confidence: 99%

Added value of subjective assessed functional capacity before non-cardiac surgery in predicting postoperative myocardial injury

Marsman

Waes

Grobben

et al. 2020

European Journal of Preventive Cardiology

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Background Functional capacity is used as an indicator for cardiac testing before non-cardiac surgery and is often performed subjectively. However, the value of subjectively estimated functional capacity in predicting cardiac complications is under debate. We determined the predictive value of subjectively assessed functional capacity on postoperative cardiac complications and mortality. Design An observational cohort study in patients aged 60 years and over undergoing elective inpatient non-cardiac surgery in a tertiary referral hospital. Methods Subjective functional capacity was determined by anaesthesiologists. The primary outcome was postoperative myocardial injury. Secondary outcomes were postoperative inhospital myocardial infarction and one year mortality. Logistic regression analysis and area under the receiver operating curves were used to determine the added value of functional capacity. Results A total of 4879 patients was included; 824 (17%) patients had a poor subjective functional capacity. Postoperative myocardial injury occurred in 718 patients (15%). Poor functional capacity was associated with myocardial injury (relative risk (RR) 1.7, 95% confidence interval (CI) 1.5–2.0; P < 0.001), postoperative myocardial infarction (RR 2.9, 95% CI 1.9–4.2; P < 0.001) and one year mortality (RR 1.7, 95% CI 1.4–2.0; P < 0.001). After adjustment for other predictors, functional capacity was still a significant predictor for myocardial injury (odds ratio (OR) 1.3, 95% CI 1.0–1.7; P = 0.023), postoperative myocardial infarction (OR 2.0, 95% CI 1.3–3.0; P = 0.002) and one year mortality (OR 1.4, 95% CI 1.1–1.8; P = 0.003), but had no added value on top of other predictors. Conclusions Subjectively assessed functional capacity is a predictor of postoperative myocardial injury and death, but had no added value on top of other preoperative predictors.

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“…Six-minute walk test distance is strongly correlated with the ventilatory threshold and distance can be used to risk stratify patients before major noncardiac surgery. 35,36 Additionally, Reddy et al identified the time to complete an inclinic stair climb test as the single strongest predictor of perioperative complications in patients undergoing major abdominal surgery, and this test outperformed the American College of Surgeons National Surgical Quality Program score (area under the curve, 0.81 vs. 0.62; P < 0.0001). 37 More objective measures of patient physical activity, either through patient worn accelerometers or brief exercise tests, may further improve perioperative risk stratification.…”

Section: Discussionmentioning

confidence: 99%

Accuracy of Physical Function Questions to Predict Moderate-Vigorous Physical Activity as Measured by Hip Accelerometry

et al. 2019

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Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background Functional capacity assessment is a core component of current perioperative cardiovascular evaluation and management guidelines for noncardiac surgery. The authors investigated the ability of standardized physical function questions to predict whether participants engaged in moderate physical activity as measured by hip accelerometers. Methods Participant responses to physical functioning questions and whether they engaged in moderate physical activity were extracted from the National Health and Nutrition Examination Survey (2003 to 2004 and 2005 to 2006). Physical activity intensity was measured using hip accelerometers. Adult participants with at least one Revised Cardiac Risk Index condition were included in the analysis. Standardized physical function questions were evaluated using a classification and regression tree analysis. Training and test datasets were randomly generated to create and test the analysis. Results Five hundred and twenty-two participants were asked the physical functioning questions and 378 of 522 (72.4%) had a bout of moderate-vigorous activity. Classification and regression tree analysis identified a “no difficulty” response to walking up 10 stairs and the ability to walk two to three blocks as the most sensitive questions to predict the presence of a 2-min bout of moderate activity. Participants with positive responses to both questions had a positive likelihood ratio of 3.7 and a posttest probability greater than 90% of a 2-min bout of moderate-vigorous activity. The sensitivity and specificity of positive responses to physical functioning questions in the pruned tree were 0.97 (95% CI, 0.94 to 0.98) and 0.16 (95% CI, 0.10 to 0.23) for training data, and 0.88 (95% CI, 0.75 to 0.96) and 0.10 (95% CI, 0.00 to 0.45) for the test data. Participants with at least one 2-min bout of moderate activity had a greater percentage of overall daily active time (35.4 ± 0.5 vs. 26.7 ± 1.2; P = 0.001) than those without. Conclusions Standardized physical function questions are highly sensitive but poorly specific to identify patients who achieve moderate physical activity. Additional strategies to evaluate functional capacity should be considered.

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Using the 6-minute walk test to predict disability-free survival after major surgery

Cited by 49 publications

References 25 publications

Integration of the Duke Activity Status Index into preoperative risk evaluation: a multicentre prospective cohort study

Integration of the Duke Activity Status Index into preoperative risk evaluation: a multicentre prospective cohort study

Added value of subjective assessed functional capacity before non-cardiac surgery in predicting postoperative myocardial injury

Accuracy of Physical Function Questions to Predict Moderate-Vigorous Physical Activity as Measured by Hip Accelerometry

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