The University of Southampton
University of Southampton Institutional Repository

Assessment of functional capacity before major non-cardiac surgery: an international, prospective cohort study

Assessment of functional capacity before major non-cardiac surgery: an international, prospective cohort study
Assessment of functional capacity before major non-cardiac surgery: an international, prospective cohort study

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 (<4), moderate (4–10), or good (>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.

0140-6736
2631-2640
Wijeysundera, Duminda N.
4163d34d-519b-46cb-8305-3a68f8c53d53
Pearse, Rupert M.
50f634bc-77c8-4f69-8650-e2b0a29ceaed
Shulman, Mark A.
09ed9bd6-c28a-4365-8537-69eac44f38c0
Abbott, Tom E.F.
3602247a-7748-4d92-b28c-b346a759ecc6
Torres, Elizabeth
7aa8663c-8417-4621-83bd-6c1351d34769
Ambosta, Althea
b9e6e45c-4370-423d-9d1b-4fd01b9e25c4
Croal, Bernard L.
c9a7d504-2d06-43e7-8c9b-0ab74f4a7b6a
Granton, John T.
fb8942ee-3bfa-4420-b753-f30b22cf2291
Thorpe, Kevin E.
3ca78e06-9b6d-404e-bd48-3b88a4e51176
Grocott, Michael P.W.
1e87b741-513e-4a22-be13-0f7bb344e8c2
Farrington, Catherine
00a9f057-144e-4d0a-988b-f60a43003920
Myles, Paul S.
3c704c43-b054-4e46-9dd0-c383c295b686
Cuthbertson, Brian H.
6847b8f3-93c3-49d2-8bd9-a0bb5393541c
Wallace, Sophie
9bd8dd85-bc6f-42c7-9f73-2a294af19585
Thompson, Bruce
0b7b7407-57cb-4502-9e32-152a2f3b0c2f
Ellis, Mathew
d2579956-0aa7-4877-afff-c7a37f69d971
Borg, Brigette
e1f66e0d-75ec-4009-9d5f-235d1ad4d663
Kerridge, Ross K.
1d4c729f-3a72-4b69-b9b7-5fa46e01ad11
Douglas, Jeanene
63c63751-254d-4a6f-8905-4463296c4525
Brannan, John
73538461-badb-4eff-9828-b0d522d9dc7a
Pretto, Jeff
d0b9eee3-3904-42b3-9e9f-31afc9d42a2f
Godsall, Guy
f8474600-88fb-4942-8dd2-40f745aea795
Beauchamp, Nicola
89f2f7db-147b-41e4-b323-eec59d32187b
Allen, Sandra
821d3d2c-b6b3-4cac-97c1-4288f4ac6b27
Kennedy, Ann
bc6bcae4-aa83-4b35-9b99-102af8a275ea
Wright, Ewan
7cfe9e73-9c29-49ab-a78a-aa35b4022970
Malherbe, Johan
35449f11-fa02-4525-90d8-b5a28c6de7ab
Ismail, Hilmy
bf0d3029-0760-4d18-88a7-d269acf6b937
Riedel, Bernhard
3d42b33b-1964-4ebd-a09b-e086da21f0cb
Melville, Andrew
048fee0e-7ef9-4118-9c21-d29a0ee361cc
Sivakumar, Harry
a3c1159f-161f-42d2-81d6-4775b186f517
Murmane, Andrew
e62cade6-d7bf-4635-b585-e6f9712c69e0
Kenchington, Kay
312eecf6-84f7-4380-9e6d-4afdf84114b1
Kirabiyik, Yesim
204d3104-982d-4e41-b187-40f92eb4abbb
Gurunathan, Usha
d557adc7-6ad3-473b-924f-56fa3d7c51f4
Stonell, Chris
1ce9fd46-965e-4b1c-b8a9-2723b6e32770
Brunello, Kate
abd88286-6e44-4118-8ac6-4bb8a7b5097e
Steele, Katherine
95565d64-0461-432c-bd87-c81c22683d7c
Tronstad, Oystein
31fba437-74a7-44ea-812e-4d32cffbec88
Masel, Philip
c34f6d5b-ebaa-4257-82e3-41ef8080a7f5
Dent, Annette
8ba2f163-ac2a-4963-9876-52a4989e2509
Smith, Emma
49c1f35c-4a4a-4e67-853a-795a83361e92
Bodger, Alanna
ede0021f-3063-46fa-951d-cceff72e879f
Abolfathi, Miriam
6856c6e9-0cd0-4b26-9afd-ad5de30f1d35
Painter, Thomas W.
251603c4-4c3b-4349-9d78-a3ba6171d29b
Hunt, Anna
a31770b6-70ab-4639-b870-d55aab72d299
Jack, Sandy
a175e649-83e1-4a76-8f11-ab37ffd954ea
Levett, Denny
1743763a-2853-4baf-affe-6152fde8d05f
Edwards, Mark
590cde38-5395-40fd-833c-9e0622adada3
Loughney, Lisa
9c3e7db1-468b-405c-b32f-cedd9cc251fe
METS study investigators
Wijeysundera, Duminda N.
4163d34d-519b-46cb-8305-3a68f8c53d53
Pearse, Rupert M.
50f634bc-77c8-4f69-8650-e2b0a29ceaed
Shulman, Mark A.
09ed9bd6-c28a-4365-8537-69eac44f38c0
Abbott, Tom E.F.
3602247a-7748-4d92-b28c-b346a759ecc6
Torres, Elizabeth
7aa8663c-8417-4621-83bd-6c1351d34769
Ambosta, Althea
b9e6e45c-4370-423d-9d1b-4fd01b9e25c4
Croal, Bernard L.
c9a7d504-2d06-43e7-8c9b-0ab74f4a7b6a
Granton, John T.
fb8942ee-3bfa-4420-b753-f30b22cf2291
Thorpe, Kevin E.
3ca78e06-9b6d-404e-bd48-3b88a4e51176
Grocott, Michael P.W.
1e87b741-513e-4a22-be13-0f7bb344e8c2
Farrington, Catherine
00a9f057-144e-4d0a-988b-f60a43003920
Myles, Paul S.
3c704c43-b054-4e46-9dd0-c383c295b686
Cuthbertson, Brian H.
6847b8f3-93c3-49d2-8bd9-a0bb5393541c
Wallace, Sophie
9bd8dd85-bc6f-42c7-9f73-2a294af19585
Thompson, Bruce
0b7b7407-57cb-4502-9e32-152a2f3b0c2f
Ellis, Mathew
d2579956-0aa7-4877-afff-c7a37f69d971
Borg, Brigette
e1f66e0d-75ec-4009-9d5f-235d1ad4d663
Kerridge, Ross K.
1d4c729f-3a72-4b69-b9b7-5fa46e01ad11
Douglas, Jeanene
63c63751-254d-4a6f-8905-4463296c4525
Brannan, John
73538461-badb-4eff-9828-b0d522d9dc7a
Pretto, Jeff
d0b9eee3-3904-42b3-9e9f-31afc9d42a2f
Godsall, Guy
f8474600-88fb-4942-8dd2-40f745aea795
Beauchamp, Nicola
89f2f7db-147b-41e4-b323-eec59d32187b
Allen, Sandra
821d3d2c-b6b3-4cac-97c1-4288f4ac6b27
Kennedy, Ann
bc6bcae4-aa83-4b35-9b99-102af8a275ea
Wright, Ewan
7cfe9e73-9c29-49ab-a78a-aa35b4022970
Malherbe, Johan
35449f11-fa02-4525-90d8-b5a28c6de7ab
Ismail, Hilmy
bf0d3029-0760-4d18-88a7-d269acf6b937
Riedel, Bernhard
3d42b33b-1964-4ebd-a09b-e086da21f0cb
Melville, Andrew
048fee0e-7ef9-4118-9c21-d29a0ee361cc
Sivakumar, Harry
a3c1159f-161f-42d2-81d6-4775b186f517
Murmane, Andrew
e62cade6-d7bf-4635-b585-e6f9712c69e0
Kenchington, Kay
312eecf6-84f7-4380-9e6d-4afdf84114b1
Kirabiyik, Yesim
204d3104-982d-4e41-b187-40f92eb4abbb
Gurunathan, Usha
d557adc7-6ad3-473b-924f-56fa3d7c51f4
Stonell, Chris
1ce9fd46-965e-4b1c-b8a9-2723b6e32770
Brunello, Kate
abd88286-6e44-4118-8ac6-4bb8a7b5097e
Steele, Katherine
95565d64-0461-432c-bd87-c81c22683d7c
Tronstad, Oystein
31fba437-74a7-44ea-812e-4d32cffbec88
Masel, Philip
c34f6d5b-ebaa-4257-82e3-41ef8080a7f5
Dent, Annette
8ba2f163-ac2a-4963-9876-52a4989e2509
Smith, Emma
49c1f35c-4a4a-4e67-853a-795a83361e92
Bodger, Alanna
ede0021f-3063-46fa-951d-cceff72e879f
Abolfathi, Miriam
6856c6e9-0cd0-4b26-9afd-ad5de30f1d35
Painter, Thomas W.
251603c4-4c3b-4349-9d78-a3ba6171d29b
Hunt, Anna
a31770b6-70ab-4639-b870-d55aab72d299
Jack, Sandy
a175e649-83e1-4a76-8f11-ab37ffd954ea
Levett, Denny
1743763a-2853-4baf-affe-6152fde8d05f
Edwards, Mark
590cde38-5395-40fd-833c-9e0622adada3
Loughney, Lisa
9c3e7db1-468b-405c-b32f-cedd9cc251fe

Wijeysundera, Duminda N., Pearse, Rupert M., Shulman, Mark A., Abbott, Tom E.F., Torres, Elizabeth, Ambosta, Althea, Croal, Bernard L., Granton, John T., Thorpe, Kevin E., Grocott, Michael P.W., Farrington, Catherine, Myles, Paul S., Cuthbertson, Brian H., Wallace, Sophie, Thompson, Bruce, Ellis, Mathew, Borg, Brigette, Kerridge, Ross K., Douglas, Jeanene, Brannan, John, Pretto, Jeff, Godsall, Guy, Beauchamp, Nicola, Allen, Sandra, Kennedy, Ann, Wright, Ewan, Malherbe, Johan, Ismail, Hilmy, Riedel, Bernhard, Melville, Andrew, Sivakumar, Harry, Murmane, Andrew, Kenchington, Kay, Kirabiyik, Yesim, Gurunathan, Usha, Stonell, Chris, Brunello, Kate, Steele, Katherine, Tronstad, Oystein, Masel, Philip, Dent, Annette, Smith, Emma, Bodger, Alanna, Abolfathi, Miriam, Painter, Thomas W., Hunt, Anna, Jack, Sandy, Levett, Denny, Edwards, Mark and Loughney, Lisa , METS study investigators (2018) Assessment of functional capacity before major non-cardiac surgery: an international, prospective cohort study. The Lancet, 391 (10140), 2631-2640. (doi:10.1016/S0140-6736(18)31131-0).

Record type: Article

Abstract

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 (<4), moderate (4–10), or good (>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.

Full text not available from this repository.

More information

Accepted/In Press date: 15 May 2018
e-pub ahead of print date: 28 June 2018
Published date: 30 June 2018

Identifiers

Local EPrints ID: 424950
URI: http://eprints.soton.ac.uk/id/eprint/424950
ISSN: 0140-6736
PURE UUID: b7672a7f-a1fe-4eea-9b52-302ccf024fbb
ORCID for Michael P.W. Grocott: ORCID iD orcid.org/0000-0002-9484-7581

Catalogue record

Date deposited: 05 Oct 2018 16:30
Last modified: 17 Dec 2019 01:42

Export record

Altmetrics

Contributors

Author: Duminda N. Wijeysundera
Author: Rupert M. Pearse
Author: Mark A. Shulman
Author: Tom E.F. Abbott
Author: Elizabeth Torres
Author: Althea Ambosta
Author: Bernard L. Croal
Author: John T. Granton
Author: Kevin E. Thorpe
Author: Catherine Farrington
Author: Paul S. Myles
Author: Brian H. Cuthbertson
Author: Sophie Wallace
Author: Bruce Thompson
Author: Mathew Ellis
Author: Brigette Borg
Author: Ross K. Kerridge
Author: Jeanene Douglas
Author: John Brannan
Author: Jeff Pretto
Author: Guy Godsall
Author: Nicola Beauchamp
Author: Sandra Allen
Author: Ann Kennedy
Author: Ewan Wright
Author: Johan Malherbe
Author: Hilmy Ismail
Author: Bernhard Riedel
Author: Andrew Melville
Author: Harry Sivakumar
Author: Andrew Murmane
Author: Kay Kenchington
Author: Yesim Kirabiyik
Author: Usha Gurunathan
Author: Chris Stonell
Author: Kate Brunello
Author: Katherine Steele
Author: Oystein Tronstad
Author: Philip Masel
Author: Annette Dent
Author: Emma Smith
Author: Alanna Bodger
Author: Miriam Abolfathi
Author: Thomas W. Painter
Author: Anna Hunt
Author: Sandy Jack
Author: Denny Levett
Author: Mark Edwards
Author: Lisa Loughney

University divisions

Download statistics

Downloads from ePrints over the past year. Other digital versions may also be available to download e.g. from the publisher's website.

View more statistics

Atom RSS 1.0 RSS 2.0

Contact ePrints Soton: eprints@soton.ac.uk

ePrints Soton supports OAI 2.0 with a base URL of http://eprints.soton.ac.uk/cgi/oai2

This repository has been built using EPrints software, developed at the University of Southampton, but available to everyone to use.

We use cookies to ensure that we give you the best experience on our website. If you continue without changing your settings, we will assume that you are happy to receive cookies on the University of Southampton website.

×