Cardiopulmonary exercise testing as a screening test for perioperative management of major surgery in the elderly

Study objective: To develop an integrated strategy for the identification a nd subsequent management of high-risk patients in order to reduce both morb idity and mortality. Design: Prospective consecutive series in which all patients underwent card iopulmonary exercise (CPX) testing. Setting: CPX laboratory and level 3 ICU and high-dependency unit (HDU) of a metropolitan teaching hospital. Patients: Five hundred forty-eight patients > 60 years of age (or younger w ith known cardiopulmonary disease) scheduled for major intra-abdominal surg ery. Interventions: The patients were assigned to one of three management s trategies (ICU, HDU, or ward) based on the anaerobic threshold (AT) and ECG evidence of myocardial ischemia as determined by CPX testing that was perf ormed as part of the presurgery evaluation, and by the expected oxygen dema nd stress of the surgical procedure. Results: Overall mortality was 3.9%. Forty-three percent of deaths were att ributed to poor cardiopulmonary function, as detected preoperatively. There were no deaths related to cardiopulmonary complications in any patient dee med fit for major abdominal surgery and ward management, as determined by C PX testing. Conclusions: In elderly patients undergoing major intra-abdominal surgery, the AT, as determined by CPX testing, is an excellent predictor of mortalit y from cardiopulmonary causes in the postoperative period. Preoperative scr eening using CPX testing allowed the identification of high-risk patients a nd the appropriate selection of perioperative management.