I. FIRST CASE PRESENTATION

PBLD 9 ‐ Do you need Preoperative Functional Tests? Breandan Sullivan, MD* and Marc J. Licker, MD° *University of Colorado, Denver (CO); °University H...
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PBLD 9 ‐ Do you need Preoperative Functional Tests? Breandan Sullivan, MD* and Marc J. Licker, MD° *University of Colorado, Denver (CO); °University Hospital, Geneva (Switzerland) At the conclusion of this PBLD, the participant will be able to: 1. To describe the functional tests available to assess patients undergoing thoracic surgery 2. To discuss the indications for specific functional tests before thoracotomy 3. To interpret the results of PFTs (spirometry, CO diffusing capacity, blood gas analysis, perfusion/ventilation lung scan, cardiopulmonary exercise test). 4. To assess patient and procedure‐related risk factors in thoracic surgery I. FIRST CASE PRESENTATION A 65 year old male is referred to you by an oncologic surgeon for pre-operative evaluation for tumor de-bulking surgery. The patient is a lifelong smoker with extensive peritoneal spread of an appendiceal cancer. The surgical plan is exploratory laparatomy with tumor debulking with possible wedge or lobe resection or pneumonectomy. The patient did undergo mediastenoscopy and bronchoscopy that were clear of bronchogenic involvement or mediastinal spread of the cancer. With good surgical resection the patient is more likely to respond to chemotherapy. With chemotherapy and extensive surgical resection there is a potential cure. The patient is a retired farmer and per history has good functional status; although this has not been quantified. On physical exam the patient has conversational dyspnea. He has a positive fluid wave on abdominal exam and absent breath sounds in his right lung. The patient has normal kidney and liver function. The patient was referred for pulmonary function testing and we found to have a FVC 35% predicted, an FEV1 of 50% predicted, a DLCO 40% predicted, with a DLCO/VA that was normal and a FEV1/FVC 70% predicted. Unfortunately, the patient has recently injured his knee when he slipped on the ice and was unable to do a VO2 max test. Since diagnosis, the patient has required increased amounts of narcotic pain medicine, has developed a large amount of ascites with positive tumor cells, and has been placed on oxygen 2 L nasal cannula for hypoxemia noted on routine clinic visit. QUESTIONS 1. What preoperative testing may assist in risk assessment of this patient’s postoperative pulmonary complications? 2. If the patient is unable to exercise prior to surgery what level of functional status predicts increased complications after thoracic surgery? 3. Does the thoracic surgical approach make any difference in post-operative recovery? In particular does it matter if the surgeon uses a thorascopic approach versus an open approach in lobectomy or wedge resection? 4. With the improved technique of lung volume reduction surgery does this change your concern over marginal preoperative pulmonary function tests? 5. Would any imaging studies assist in your preoperative management or interpretation of this patient’s pulmonary function tests? 6. What potential benefits does epidural analgesia provide for this patient? 1

CASE CONTINUATION Prior to surgery the patient is admitted to the hospital for worsening hypoxemia and shortness of breath. The patient has an arterial blood gas drawn in the emergency room pH 7.49 pCO2 30 pO2 45 on room air. The chest x-ray reveals complete opacification of the right hemithorax consistent with a large pleural effusion. An ultrasound confirms the diagnosis. QUESTIONS 1. Does the presence of a large pleural effusion change your interpretation of the patients previous pulmonary function testing? 2. How soon should the patient’s hypoxemia improve after a large volume thoracentesis? 3. What are the benefits with regards to oxygenation, thoracic mechanics, and hemodynamics? What are the risks of large volume thoracentesis with regards to oxygenation? II. SECOND CASE PRESENTATION

A 54 year old man has a medical history of hypertension (since 1998), myocardial infarct (in 2009) and COPD (since 2007). Over the last 3 months, he lost 6 kg (from 83 to 77 kg) and his physician made an initial diagnosis of pneumonia. After antibiotic treatment, chest X rays and CT-scan showed a large cavitated lesion (4.5 x 3.8 x 2.7 cm) in the left lower lobe. FDG- PET scan showed abnormal accumulation of the radiotracer (fluorine-18 deoxy-glucose) within the lung mass and several ipsilateral hilar nodes. An adenoarcinoma was diagnosed from histological examination of transmural biopsies taken via flexible fibroscopy; all nodes were negative for cancer. At the anesthesia consultation, the patient, -a busy restaurant owner-, presents with no fever, a dry cough, no orthopnea and moderate dyspnea on exertion. Current medications include aspirin, losartan, bisoprolol and inhaled salbutamol. He has a 65 packyear history of smoking and drinks an average of 4 beers per day. Chest examination reveals wheezes and vital signs are unremarkable (BP 135/80 mmHg, HR 65 b/min). The patient is 171 cm tall and weighed 77 kg. The ECG shows a sinus rhythm (62b/min) and Q waves in peripheral leads DII, DIII and aVF. Patient haemoglobin level is 102.5 g/L, serum creatinine is elevated at 175 mcm/L (eGFR 45 ml/min) and CRP is 25 mg/L (nl < 1). A recent echocardiogram demonstrated left ventricular hypertrophia with well preserved LV ejection fraction (60%), abnormal diastolic relaxation (transmitral flow E/A 0.7) and normal valvular function. In agreement with the oncologist and chest physician, the thoracic surgeon plan to perform a left lower lobectomy or left pneumonectomy through an antero-lateral thoracotomy. QUESTIONS 1. Which diagnostic tests are helpful for the oncologists, chest physician and surgeon? 2. What is the expected survival of this patient after a curative resection? 3. What is (are) the aim(s) of preoperative functional assessment 4. Which functional test(s) should be ordered in priority?

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CASE CONTINUATION Pulmonary function tests (body plethysmography) show significant reductions in FEV1 (2.5 L, 76% predicted) and DLCO (60.5% predicted); FVC is in the normal range (4.2 L, 103% predicted) whereas TLC, FRC and RV are all increased (6.6 L, 97% predicted; 3.5 L, 130% pred; 2.4L, 137% pred). Arterial blood gas analysis shows: pH 7.43, PaCO2 4.8 kPa, PaO2 13.5 kPa (room air), Bicarbonate 28 mm/l, BE +0.7 mm/l. Chest CT-scan shows distal collapse of most the lower lobe beyond the tumour. QUESTIONS 5. What type of respiratory dysfunction presents this patient? 6. Would you order additional tests before thoracotomy? 7. How can you estimate postoperative lung function in this patient (ppoFEV1, ppoDLCO)? 8. Which value of ppoDLCO and ppoFEV1are associated with poor quality of life? CASE CONTINUATION Based on the number of resected segments, postoperative predicted FEV1 is estimated at 65% (predicted, 1.97 L) for a LL lobectomy and 43% (1.31 L) for a left pneumonectomy; similarly, ppoDLCO is calculated at 48% ( lobectomy) and 32% (pneumonectomy). However, a large part of the LL is already collapsed (3 of 4 segments) and therefore contributes little to ventilation and gas exchange. In the left lung (total of 9 segments), only 6 out of 9 segments are functional. Hence, the denominator in the calculation can be changed from 15 to 18 (lobectomy) and from 10 to 13 (pneumonectomy). After correcting for non-functional segments, ppoFEV1 is 78% (or 56%) and ppoDLCO is 57% (or 41%) in case of LLL (or pneumonectomy). Preop tests

Actual Predicted in % (L)

Extent of resection

Segments remaining Predicted postop in % after resection

FEV1

2.5

82 (3.04)

Left lower lobectomy

15/19

65% (1.97L*) ppoFEV1

2.5

82 (3.04)

Left pneumonectomy

10/19

43% (1.31L)

60.5

Left lower lobectomy

15/19

48%

60.5

Left pneumonectomy

10/19

32%

DLCO

FEV1 DLCO

2.5

82 (3.04)

Left lower lobectomy

Correcting for open segments Predicted postop in % 18/19 78% (2.37L)

2.5

82 (3.04)

Left pneumonectomy

13/19

56% (1.71)

60.5

Left lower lobectomy

18/19

57%

60.5

Left pneumonectomy

13/19

41%

*calculated as ppoFEV1 2.5x15/19 =1.97L or 2.5x15/19)/3.04=65% predicted value

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Finally, to explore the aerobic capacity of this apparently fit patient, a cardiopulmonary exercise test (CPET) is performed and the following results are obtained: Rest (baseline)

Anaerobic threshold

Peak effort

Power, watts

-

115

150

VO2 ml/min/kg

4.4 (338 ml)

13 (1001 ml)

18 (71% pred, 1386 ml)

Borg dyspnea / leg fatigue

-

1/4

3/6

VE / VCO2

49

38

41

VE / VO2

34

37

50

HR

83

119

146

BP syst/diast

128/73

169/87

205/102

Pulse O2 ml/beat

4.1

8.4

9.4

QUESTIONS 9. How do you define the aerobic capacity and what are the influencing factors? 10. How do you rate the risk of perioperative death and major cardiovascular and pulmonary complications? 11. Are there alternative tests for evaluating patient’s fitness and aerobic capacity? If the patient is unable to perform a standardized exercise test (treadmill, bicyle,…) how would you proceed? 12. Do you think that the surgical procedure should be postponed in order to optimize patient functional condition?

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ANSWERS Q1: 1) Chest X rays and CT-scan 2) PET scan, 3) tissue biopsies (direct transbronchial or endobronchial ultrasound-guided [EBUS], mediastinoscopy/thoracoscopy/minithoracotomy under GA) As with most cancer, the TNM system (T= tumor, N=node, M=metastasis) has been adopted for staging classification. It is solely based on the anatomic extent of disease (Fig 1). Clinical staging is determined using all information obtained prior to any treatment by CT/PET scans and invasive staging techniques (mediastinoscopy or transbronchial/transthoracic biopsy) whereas pathologic staging is determined after a resection has been carried out (histological examination of the resected mass and lung tissue).

The differential diagnosis in this patient includes lung abscess, lung metastasis, and lung carcinoma MarieBamberger disease (hypertrophic osteoarthropathy). CT scans of the chest and abdomen provide anatomic details while PET imaging using 8F-2-deoxy-D-glucose (FDG) is helpful to identify malignant lymph nodes (sensitivity of 74% versus 51% with CT scan; specificity of 85% versus 85% with CT-scan). Abnormal findings detected by CT/PET scans should be confirmed by tissue biopsy to ensure accurate diagnosis since pulmonary PET scans may be falsely positive in inflammatory, infectious, or other nonneoplastic processes. The overall agreement of clinical TNM (cTNM) staging established by CT compared with post-operative pathological TNM (pTNM) is not significantly better than 50%. Magnetic resonance imaging (MRI) is helpful for assessing the extension of the tumour within the heart or great vessels and MRI is better than CT at

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distinguishing the lung mass from the adjacent atelectasis or consolidation, particularly in case of fibrosis post-radiotherapy Surgical resection remains the mainstay of treatment for all patients with stage I and II nonsmall cell lung carcinoma (NSCLC) that is, those patients with no evidence of mediastinal disease or invasion of local organs. The role of surgery for stage III disease is more controversial. Patients with completely resectable primary tumors (ie, T4 N0) have a much better prognosis than those with spread to ipsilateral mediastinal or subcarinal lymph nodes (ie, N2), signifying that spread beyond the primary tumor is associated with a poor prognosis. Patients with stage IIIB or IV tumors are almost never surgical candidates. Chemotherapy is only beneficial in patients with good performance status and less than 10% weight loss.

TNM Stage Treatment Wedge resection or segmentectomy 0 (in situ) Photodynamic therapy, electrocautery, laser, cryo-therapy Wedge resection or segmentectomy, lobectomy I Wedge resection or segmentectomy, lobectomy II or pneumonectomy Chemotherapy before or after surgery Surgery before or after chemotherapy IIA Surgery followed by chemo-radiotherapy or only radiotherapy Surgery followed by radiotherapy IIIB and IV Non-surgical palliative treatment: chemo-RX-laser

Alternative

External radiation External radiation

External radiotherapy Internal radiotherapy or laser therapy

About 20 to 25% of patients with NSCLC are potential candidates for surgical resection because of the advanced stages at which the cancer is diagnosed or because of comorbid conditions. Among patients with anatomically resectable disease, 20 to 40% are denied any surgical treatment due to poor lung function. Given its rapid dissemination, SCLC has a much poorer prognosis and less than 5% of patients with SCLC are deemed suitable to surgery (T1-T2,N0M0). Q2: The patient has a adenocarcinoma TNM stage IB and the expected 5-year survival following surgery would range between 45 and 65%. Loss of weight, anemia and ongoing inflammation negatively impact survival and accentuates fatigue in cancer patients. In 2005, there were 172,570 new cases of lung cancer in US; they are mainly related to tobacco smoke (8090%) and to a lesser extent to genetic factors, radon gas, asbestos, and air pollution. NSCLC with its 4 histological subtypes (adenocarcinoma, squamous cell LC large-cell LC and neuroendocrine tumor) accounts for 80 % and small cell carcinoma (SCLC) for 13 to 20% of all cases. NSCLC should be tested for epidermal growth factor receptor (EGFR) mutations as the presence of these mutations is predictive of responsiveness to EGFR tyrosine kinase inhibitors. The annual number of deaths from lung cancer is greater than the numbers of deaths from breast, colon, and prostate cancers combined. Currently, the 5-y survival rates of NSCLC are 16% in the United States and 5% in the United Kingdom. Q3: preop FTs have 3 main goals: 1) to document cardiac and pulmonary function (severity of impairment), 2) to stratify the risk of early postoperative major complications (mortality, respiratory complications, cardiac complications, 3) to predict the loss of (pulmonary) function after lung resection (for the long term). Q4: According to recent guidelines (ACCP, BTS and ERS/ESCTS), preoperative assessment should start with the revised cardiac risk index (RCRI) and clinical examination. In this patient, the following steps are indicated: 1) Cardiac assessment to document coronary artery disease (CPET, scintigraphy, stress echocardiography), 2) Spirometry/plethysmography, 3) DLCO.

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Revised Cardiac Risk Index (RCRI, Lee)* High risk surgery 1pt Coronary Artery Disease 1pt Congestive Heart Failure: 1pt Cerebrovascular Disease: 1pt Diabetes Mellitus on Insulin: 1pt Serum Creatinine > 2mg/dl 1pt

Thoracic RCRI° Pneumonectomy Coronary Artery Disease Cerebrovascular Disease: Serum Creatinine > 2mg/dl

*Cardiac arrest, ventric. Fibrillation, complete heart block, Myoc. Infarct, pulmonary emblism

°Cardiac arrest, complete heart block, Myoc. Infarct, pulmonary edema

1.5 pt 1.5 pt 1.5 pt 1 pt

RCRI: 0-1pt:low risk (< 5%); 2 pts: moderate risk (5-10%), >3 pts: high risk (>10%) Thoracic RCRI: 0-1pt:low risk (< 5%); 1-1.5 pts: moderate risk (5-10%), >2.5 pts: high risk (>10%) Q5: the patient presents moderate grade (II) COPD according to the GOLD classification. Stage of COPD 0 : at risk 1 : Mild 2 : Moderate

3 : Severe 4 : Very Severe

Test results Normal lung test • FEV1/FVC < 0.7 • FEV1 > 80% • FEV1/FVC < 0.7 • FEV1 50 - 80% • • • • •

Signs • Coughing up mucus, every day for some time • Cough + • a little breathless when walking quickly • Cough ++ • breathless if working hard, walking quickly, or doing household jobs FEV1/FVC < 0.7 • Difficult to work physically, fatigability ++ FEV1 30 - 50% • Impaired exercise tolerance FEV1/FVC < 0.7 • Unable to to go to work or doing jobs FEV1 30 - 50% with other • Difficult to walk across the room signs of lung failure • Possible cor pulmonale FEV1 < 30%

Q6: standardized cardiopulmonary exercise testing (CPET) that would include cardiac stress testing (ECG monitoring).

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Q7: predicted postoperative FEV1 and DLCO (ppoFEV1 and ppoDLCO) based on functional segment calculation, CT-perfusion scan or ventilation/perfusion scintigraphy. Right: 3 lobes, 10 segments

Left: 2 lobes, 9 segments

Q8: ppoDLCO/ppoFEV1 < 30% are associated with impaired functional status, loss of autonomy in daily living activities. Q9: the aerobic capacity represents the maximal amount of physiologic work that an individual can do as measured by oxygen consumption. It is mainly influenced by cardiac function (cardiac output), pulmonary function (gas exchange and ventilation) and skeletal muscles condition (ability 8

to extract and utilize oxygen in contracting cells). PeakVO2 is lower in woman (than in man) and decreases with age. Q10: poor postoperative outcome entails the risk of operative death, early major complications (e.g., cardiovascular, pulmonary, infectious) as well as long-term functional impairments. • Increased risk of perioperative mortality  Thoracoscore which has been established in a large French cohort and further validated in US. There is an on-line calculator accessible: http://www.sfar.org/scores2/thoracoscore2.php In this patient, the risk of in-hospital mortality is estimated between 2.1% (pneumonectomy) and 0.7% (lobectomy or lesser resection). • Increased risk of major cardiopulmonary complications : if ppoFEV180% (and/or DLCO > 80%) are considered suitable candidate for lung cancer resection. Lung volumes, airway resistance/conductance, Volume-Flow curves Using a vitalograph or a pneumotachograph (flowmeter), the subject is instructed to inhale completely and to exhale as hard and as long as he can (forced spirometry); alternatively, the subject proceeds to a slow maximal expiration, followed again by maximal inspiration. Accordingly, forced or slow vital capacity (FVC, SVC), forced expiratory volume over the first sec (FEV1), the ratio of FEV1/FVC, peak airflow, forced expiratory flow at 50, 75 or 25-75 % of lung volume (FEF 50 , FEF 75 , FEF 25-75 ) can be calculated and these measured data are compared with norms or reference adjusted for body weight, height, age and gender using specific equations. The functional residual volume (FRV) and residual volume (RV) are measured by body plethysmography or a nitrogen (N 2 )/Helium (He) washout test. In case of bullous emphysema, inhaled tracer gas can only be diluted in lung areas that are connected with patent airways, hence, lower FRV and RV are obtained with the wash out technique compared with plethysmography that takes into account all residual lung gas, regardless of communication with ambient air.9 Lung capacity volumes are calculated by adding specific lung compartments (e.g., total lung capacity (TLC), residual lung volume [CRF], inspiratory and expiratory reserve capacity [IRC, ERC]). Spirometric tests can be repeated after inhalation of bronchodilating (b2-adrenergic, anticholinergic) or bronchoconstrictive agents (metacholine) to test the reversibility of an obstructive syndrome and to establish the diagnosis of hyperreactive airway disease. Importantly, determination of lung volumes, airway resistance/conductance and flow-volume curves provides diagnostic clues in the evaluation of COPD, asthma, restrictive lung disease and tracheal obstruction/compression. Grading the severity of COPD is largely based on spirometric results.

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Gas exchange The diffusion capacity of the lung for carbon dioxide (DLCO) reflects the efficiency of the gas diffusion across the alveolar-capillary membrane. Accordingly, DLCO will be reduced by restriction of the capillary surface area available for gas diffusion (e.g., pneumonectomy, lung collapse, severe emphysema), increased thickness of the interstium or filling of alveolar space with fluid and cellular infiltrates (e.g., cardiogenic edema, capillary leak syndrome, fibrosis). Low haemoglobin level may cause false positive results. After a single breath of a mixture containing 0.3% of CO and 10% helium, the patient holds his breath for 10-20 sec and then exhales. The first 0.75 L of exhaled gas is discarded and the CO concentration is analyzed while its amount that crosses the alveolar-capillary membrane is calculated. CO is chosen because of its high affinity for Hb; helium, an inert gas unabsorbed in the lung, is used to calculate the initial CO concentration. Of note, FEV1 are poorly correlated with DLCO. Modern blood gas analyzers allow direct measurements of pH, partial pressure of oxygen, and carbon dioxide as well as electrolytes, glucose and lactate while providing calculation of bicarbonate and base excess. Hypoxemia is a common marker of respiratory and/or heart failure. Calculation of the pO2 alveolararterial gradient (AaPaO2) associated with the determination of PaCO2 and bicarbonate/base excess is helpful to find out the cause of hypoxemia (hypercapnic ventilatory pump failure, ventilation/perfusion mismatch). The presence of hypoxemia is not considered as an independent predictor of respiratory complications whereas hypercapnia has been associated with the acute postoperative respiratory failure and major complications following non-thoracic surgery.10 Cardiopulmonary exercise testing (CPET) Thoracic surgical procedures range from mild to major stresses depending on the extent of tissue trauma and duration of surgery. The inflammatory response and the activation of both the sympathetic system and the hypothalamic-pituitary adrenal axis result in a moderate increase in oxygen consumption (VO2 +10-20%), elevated heart rate (HR), fatigue upon mobilization and muscle wasting due to enhanced catabolism.11 CPET provides a unique opportunity to explore cardiac and pulmonary physiologic reserve as well as muscular conditioning. Over a short period (5-15min), the subject exercises at increasing intensity on a cycloergometer or treadmill whilst the inspired/expired O2 and CO2 are measured along with simultaneous recordings of the ECG, HR and blood pressure. It is also possible to measure flow and volume loops. CPET has been shown to accurately detect asymptomatic coronary artery disease12 and bears predictive information of 5-year outcome following major surgery.13 According to ACCP, CPET should be performed in patients with ppoFEV1< 40% or ppoDLCO20 ml/kg/min are considered at low risk and may safely undergo major lung resection. In contrast, very low peakVO2 (4%) is associated with increased risk. A distance walked of more than 400 m is recommended as a cut-off for acceptable functional status.18 o Symptom-limited stair climbing test: the altitude and the speed of ascent correlate with peakVO2. Climbing an altitude of 16.6 to 22m (about 6 floors, 1 floor ∼ 3-3.5m) is considered an adequate stress of the cardiorespiratory system. The inability to reach 12m (3 floors) is associated with increased risk. If subjects are able to reach 20 m within 80 sec, the corresponding peakVO2 is higher than 20 ml/kg/min. 19,20 Practically, the patient is asked to climb as fast and as high without stopping; the test is completed when the patient stops (> 3sec) or reaches the target altitude of 20 or 22 m (6 floors). Pulse rate and SPO2 may be recorded before and at the end of the test. Assessment of physical fitness CPET  peakVO2

Stair climbing

Shuttle walk

Perioperative risk

> 20 ml/kg/min

Altitude of 22 m (6 floors) Speed of ascent > 15m/min

> 600 m (?)

Low

15 -20 ml/kg/min

8 to 20 m

400 m

Moderate

10 – 15 ml/kg/min < 10 ml/kg/min

High 3 to 5 m (1 floor)

Very high

Estimation of predicted postoperative FEV1 and DLCO (ppoFEV1 and ppoDLCO) Across several follow up studies, variables changes in FEV1, DLCO and peak VO2 have been reported after lung resection (table). Recovery of pulmonary function continues for approximately 6 months after lobectomy while it is usually limited to 3 months after pneumonectomy. The ppoDLCO is best correlated with long-term outcome.21 FEV1 DLCO VO2max

Preop 100% 100% 100%

Lobectomy -9 to -16% -4 to -11% 0 to -13%

Pneumonectomy -34 to -36% -20 to -28% -11 to -29%

Postoperative loss of lung function is also determined by the functional status of the resected lung part. For example, resection of emphysematous or collapsed/consolidated areas is not associated 13

with marked functional deterioration; significant improvement may even result from the expansion of healthier neighbouring lung areas. Indeed, patients with COPD typically experience smaller declines in FEV1 after lobectomy (0 to 8%) than those without COPD. Three methods are used to predict postoperative lung function: o Segment method (9/10 segments in the left/right lungs). The preop FEV1 value is multiplied by the number of segments remaining after surgery. Correction can be made for the number of obstructed segments as shown by CT-scan and bronchoscopy. Calculation can also be made using 42 subsegments (instead of 19 segments). o Quantitative CT-scan: assess the regional distribution of emphysema and ventilation function o Radionuclide scanning. Portions of the lungs with poor perfusion/ventilation are identified after the infusion/inhalation of radioactive tracers (EDTA/xenon). The radionuclide scanning outperforms all other approaches. Performance functional status, quality of life In some old and frail patients, CPET, shuttle test and stair climbing might not be possible due to musculoskeletal or neurological disabilities. The frailty status encompasses clinical, functional and biological markers. In these patients, the use of questionnaires about daily living activities (MET, Duke, WHO), and simple test of active mobilization (gait speed over 5m, podometer) has been shown to increment clinical risk stratification.22,23 In the general population, MET >8 has been associated with a lower risk of mortality and cardiovascular events.24 1. World Health Organization( WHO) or Zubrod Performance Status Scale 0: Normal activity; 1: Symptoms, but nearly fully ambulatory; 2: Some bed time, but needs to be in bed less than 50% of normal daytime; 3: Need to be in bed greater than 50% of normal daytime; 4: Unable to get out of bed

2.

MET by questionnaire (1 MET = metabolic equivalent at rest, ~3.5 mlO2/kg/min)

1 MET 2 METs 3 METs 4 METs 5 METs 6 METs 7 METs 8 METs

9 METs 10 METs 11 METs 12 METs 13 METs

Eating, getting dressed, working at a desk Taking a shower, shopping, cooking, walking down 8 steps Walking slowly on a flat surface for 1 or 2 blocks Moderate amount of work, such as vacuuming, sweeping the floors, or carrying groceries Light yard work (ie, raking leaves, weeding, sweeping, pushing a power mower), light carpentry Walking briskly, social dancing, washing the car Play 9 holes of golf carrying your own clubs; heavy carpentry, mow lawn with push mower Carrying 60 pounds, perform heavy outdoor work (ie, digging, spading soil); walking uphill Carrying groceries upstairs, move heavy furniture Jog slowly on flat surface, climb stairs quickly Bicycling at a moderate pace, sawing wood, jumping, rope (slowly) Brisk swimming, bicycle up a hill, jog 6 miles per hour Carry a heavy load (ie, a child or firewood) up 2 flights of stairs Cross-country ski, bicycling briskly, continuously Running briskly, continuously (level ground, 8 min per mile) Any competitive activity, including those that involve intermittent sprinting Running competitively, rowing competitively, bicycle riding

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3.

Duke Activity Status Index (DASI)

Take care of yourself, that is, eat dress, bathe or use the toilet? Walk indoors, such as around your house? Walk 200 yards on level ground? Climb a flight of stairs or walk up a hill? Run a short distance? Do light work around the house like dusting or washing dishes? Do moderate work around the house like vacuuming, sweeping floors, or carrying groceries? Do heavy work around the house like scrubbing floors or lifting or moving heavy furniture? Do yard work like raking leaves, weeding or pushing a power mower? Have sexual relations? Participate in moderate recreational activities like golf,bowling,swimming dancing, doubles tennis, or throwing a ball? Participate in strenuous sports like singles tennis, football, basketball, or skiing? , DASI = sum of ‘all items peak VO2 = (0·43xDASI)+9·6 ml/min

2.75 1.75 2.75 5.50 8.00 2.70 3.50 8.00 4.50 5.25 6.00 7.5

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