1. Assessment of functional capacity before major non-cardiac surgery: an international, prospective cohort study
- Author
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Tom E.F. Abbott, Johan Malherbe, Hannah Collins, Chang Joon Kim, Michelle Gertsman, Charmagne Crescini, Andrew MacCormick, Brigette Borg, J. Tai, Miriam Towns, Rene Belliard, Althea Ambosta, Rupert M Pearse, Mandeep Phull, H. Lawrence, Martin Rooms, Denny Z. H. Levett, Sandra Allen, Stuart A. McCluskey, Maria Koutra, Shaman Jhanji, Mathew Ellis, Fiona H. Marshall, Kevin E. Thorpe, Sally Hurford, Anna Tippett, Colin J. L. McCartney, Adrian Hall, Gareth L. Ackland, Paul Oh, K. Pirie, T. Ahmad, Harindra C. Wijeysundera, R Kerridge, Miriam Abolfathi, J. Douglas, Rhiannon Lifford, Simon Macklin, C. David Mazer, Edyta Niebrzegowska, Alanna Bodger, Magda Melo, J. Whalley, Marta Januszewska, Julian Dimech, Pheobe Bodger, Alistair Brown, Ann Kennedy, Douglas M Campbell, S. Olliff, Angela Jerath, Anna Maria Carrera, Anmol Yagnik, Bernhard Riedel, Andrew Murmane, Philip Masel, Manuel Pinto, Sanjay Yagnik, N Terblanche, Paul S. Myles, Leanlove Navarra, Sophie Wallace, W. Scott Beattie, Robert C M Stephens, Pal Sivalingam, Helder Filipe, Thais Creary, Geraldine Back, Guy Godsall, Natasha Tantony, Stephen Choi, Ellen Waymouth, Kirsty Everingham, Adrian D. Elliott, Chris Wilde, Sandy Jack, Natalie McMillan, Katherine Steele, Mark A Shulman, Mark J. Edwards, Helen Houston, Vincent W. S. Chan, Catherine Farrington, Lauren Day, Kushlin Higgie, Hugh Taylor, Shelly Au, John Brannan, Clare Bolger, Bruce Thompson, Andrew Melville, John Grant, Katherine Hagen, Paul Dalley, Daniel Martin, Reuben Miller, Muhammad Mamdani, Hilmy Ismail, Harry Sivakumar, Karen Salmon, N. Ami, Joanne Samuel, Graham S. Hillis, D. Bramley, H. Thompson, Ravishanar Raobaikady, Michael Lorimer, Andrew Collingwood, Yesim Kirabiyik, Michael Celinski, Ewan Wright, Usha Gurunathan, R. Sara, Carmen Corriea, Sharon Gabriel, Emma Smith, Lynn Andrews, Janarthanee Kunasingam, Ryan Jang, Kim Golder, Hance Clarke, Laura Gallego-Paredes, Kate Leslie, Jane McNeil, Thomas Painter, Timothy G. Short, Mari Liis Pakats, Brian H. Cuthbertson, Adelaide Jason-Smith, Bryony Tyrell, K. Flores, D. Mcallister, Samantha Bates, Anna Reyes, Helen A. Lindsay, Jonathan Kumar, John Granton, Richard Brull, Nicola Beauchamp, Marcin Wasowicz, Duminda N. Wijeysundera, Leanne Seaward, Kate Brunello, Mark Lum, Jeffrey J. Pretto, Lisa Loughney, Ethel Black, Ying Hu, Simon Pitt, Chris Stonell, Marlynn Ali, Ashok Raj, Kay Kenchington, Matthew Stanbrook, Michael P.W. Grocott, Annette Dent, Anna Hunt, Sarah James, A.M. Southcott, Joreline Van Der Westhuizen, Keyvan Karkouti, Ana Gutierrez del Arroyo, J. Pazmino-Canizares, N Macdonald, Leanna Lee, Richard Haslop, K. Greaves, Stephen Kynaston, Bernard L. Croal, Elizabeth B. Torres, Karen Dobson, Christian M. Beilstein, Christopher X. Wong, Oystein Tronstad, and P. Somascanthan
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Male ,medicine.medical_specialty ,Internationality ,Health Status ,030204 cardiovascular system & hematology ,Risk Assessment ,Sensitivity and Specificity ,Metabolic equivalent ,Coronary artery disease ,03 medical and health sciences ,0302 clinical medicine ,Postoperative Complications ,030202 anesthesiology ,Natriuretic Peptide, Brain ,medicine ,Humans ,Myocardial infarction ,Prospective Studies ,Prospective cohort study ,Stroke ,Aged ,Exercise Tolerance ,business.industry ,General Medicine ,Odds ratio ,Middle Aged ,medicine.disease ,Peptide Fragments ,Heart failure ,Emergency medicine ,Exercise Test ,Female ,Risk assessment ,business - Abstract
Summary Background Functional capacity is an important component of risk assessment for major surgery. Doctors' clinical subjective assessment of patients' functional capacity has uncertain accuracy. We did a study to compare preoperative subjective assessment with alternative markers of fitness (cardiopulmonary exercise testing [CPET], scores on the Duke Activity Status Index [DASI] questionnaire, and serum N-terminal pro-B-type natriuretic peptide [NT pro-BNP] concentrations) for predicting death or complications after major elective non-cardiac surgery. Methods We did a multicentre, international, prospective cohort study at 25 hospitals: five in Canada, seven in the UK, ten in Australia, and three in New Zealand. We recruited adults aged at least 40 years who were scheduled for major non-cardiac surgery and deemed to have one or more risk factors for cardiac complications (eg, a history of heart failure, stroke, or diabetes) or coronary artery disease. Functional capacity was subjectively assessed in units of metabolic equivalents of tasks by the responsible anaesthesiologists in the preoperative assessment clinic, graded as poor ( 10). All participants also completed the DASI questionnaire, underwent CPET to measure peak oxygen consumption, and had blood tests for measurement of NT pro-BNP concentrations. After surgery, patients had daily electrocardiograms and blood tests to measure troponin and creatinine concentrations until the third postoperative day or hospital discharge. The primary outcome was death or myocardial infarction within 30 days after surgery, assessed in all participants who underwent both CPET and surgery. Prognostic accuracy was assessed using logistic regression, receiver-operating-characteristic curves, and net risk reclassification. Findings Between March 1, 2013, and March 25, 2016, we included 1401 patients in the study. 28 (2%) of 1401 patients died or had a myocardial infarction within 30 days of surgery. Subjective assessment had 19·2% sensitivity (95% CI 14·2–25) and 94·7% specificity (93·2–95·9) for identifying the inability to attain four metabolic equivalents during CPET. Only DASI scores were associated with predicting the primary outcome (adjusted odds ratio 0·96, 95% CI 0·83–0·99; p=0·03). Interpretation Subjectively assessed functional capacity should not be used for preoperative risk evaluation. Clinicians could instead consider a measure such as DASI for cardiac risk assessment. Funding Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Ontario Ministry of Health and Long-Term Care, Ontario Ministry of Research, Innovation and Science, UK National Institute of Academic Anaesthesia, UK Clinical Research Collaboration, Australian and New Zealand College of Anaesthetists, and Monash University.
- Published
- 2018