Evidence map›Paper›PMID 42326382›Full record

ArticleEClinicalMedicine2026

Prognostic value of the Duke Activity Status Index for preoperative cardiac risk stratification: an international pooled cohort study.

Duminda N Wijeysundera, Brian H Cuthbertson, Emmanuelle Duceppe, Tom E F Abbott, Rupert M Pearse, Paul S Myles, Keying Xu, Julian F Daza, Calvin Diep, Leandra A Amado and 4 more

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Article in EClinicalMedicine, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.

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1 · What the graph read from it

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2 · The registry

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3 · Its place in the literature

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4 · The record

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5 · Who and what money

Authors and funding

14 authors.

Duminda N WijeysunderaDepartment of Anesthesia, St. Michael's Hospital - Unity Health Toronto, Toronto, Ontario, Canada.
Brian H CuthbertsonDepartment of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
Emmanuelle DuceppeDepartments of Medicine, Centre Hospitalier de l'Universite de Montreal and University of Montreal, Montreal, Quebec, Canada.
Tom E F AbbottFaculty of Medicine and Dentistry, Queen Mary University of London, London, UK.
Rupert M PearseFaculty of Medicine and Dentistry, Queen Mary University of London, London, UK.
Paul S MylesDepartment of Anaesthesiology and Perioperative Medicine, Alfred Hospital, Melbourne, Victoria, Australia.
Keying XuStrategic Partnerships in Health Excellence, Research, and Engagement, Unity Health Toronto, Toronto, Ontario, Canada.
Julian F DazaDivision of General Surgery, Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
Calvin DiepDepartment of Anesthesia, St. Michael's Hospital - Unity Health Toronto, Toronto, Ontario, Canada.
Leandra A AmadoDepartments of Anesthesiology and Pain Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada.
Angela JerathDepartment of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
Bernhard RiedelDepartment of Anaesthesia, Perioperative Medicine, and Pain Medicine, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.
Daniel I McIsaacDepartments of Anesthesiology and Pain Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada.
FIT After Surgery Investigators and METS Investigators

Funding

No grant is acknowledged in the PubMed record.

6 · The paper itself

Abstract

Background: Guidelines recommend structured self-reported functional capacity assessment for preoperative cardiac risk stratification, including the Duke Activity Status Index (DASI). However, evidence supporting its incremental prognostic value beyond established risk factors remains limited. We evaluated the prognostic performance of the DASI using pooled data from two prospective cohorts. Methods: We conducted a pooled cohort analysis of adults undergoing elective major non-cardiac surgery enrolled in the Measurement of Exercise Tolerance before Surgery (METS) and Functional Improvement Trajectories After Surgery (FIT After Surgery) studies, including data collected between March 2013 and April 2023. Before surgery, participants completed the Duke Activity Status Index (DASI), a structured 12-item questionnaire based on daily physical activities, and underwent routine preoperative biomarker measurement. The primary outcome was 30-day major cardiac complications (myocardial infarction or non-fatal cardiac arrest) or death. The secondary outcome was all-cause major complications. Hierarchical logistic regression assessed the incremental prognostic value of the DASI beyond age, Revised Cardiac Risk Index (RCRI), and natriuretic peptide concentration. Prognostic performance was evaluated using the likelihood ratio test (LRT), fraction of new predictive information, net reclassification improvement, c-index, calibration plots, and decision curve analysis. Findings: Among 3485 patients, 3.6% (n = 126) experienced the primary outcome and 19% (n = 647) experienced the secondary outcome. The DASI provided prognostic information beyond age, RCRI, and natriuretic peptide concentration for the primary outcome (LRT p = 0.009), and beyond age, sex, and surgery type for the secondary outcome (LRT p < 0.001). Inclusion of the DASI improved prognostic performance across multiple metrics, but overall discrimination of the final models remained modest (c-index 0.70-0.71), with limited net clinical benefit. Predicted risk associated with a given DASI score varied substantially by age, RCRI, and natriuretic peptide concentration, supporting interpretation of the DASI as a continuous prognostic marker rather than a dichotomous screening test. Interpretation: The DASI provides incremental prognostic information for preoperative cardiac risk assessment beyond guideline-recommended predictors. Its prognostic implications are modest, context-dependent, and best interpreted as a continuous prognostic marker alongside established risk factors, rather than as a stand-alone threshold-based tool. Funding: Canadian Institutes of Health Research; PSI Foundation; and the Elizabeth A. and Richard J. Currie, O.C. Chair in Translational Anesthesia Research at St. Michael's Hospital and the University of Toronto; The Ottawa Hospital Academic Medical Organization Innovation Fund; 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; Monash University.

Indexed as

Cardiac risk stratificationDuke Activity Status IndexFunctional capacityNon-cardiac surgeryPostoperative complicationsPrognosis

Identifiers

PMID42326382
PMCPMC13276150

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Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.