Distance Walked in the 6-Minute Test Soon After Cardiac Surgery*

Toward an Efficient Use in the Individual Patient

Cristina Opasich, MD; Stefania De Feo, MD; Gian Domenico Pinna, MS; Giuseppe Furgi, MD; Roberto Pedretti, MD; Domenico Scrutinio, MD; and Roberto Tramarin, MD

Study objectives: To describe the results of the 6-min walking test performed on admission to an intensive rehabilitation program after cardiac surgery and to develop, through an algorithm based on a few clinical indicators, reference tables in order to apply distance walked values more efficiently in the individual patient at his/her entry into a cardiac rehabilitation program. Setting: Intensive cardiac rehabilitation units. Patients and intervention: A total of 2,555 consecutive patients admitted between January 2001 and December 2002 to the Cardiac Rehabilitation Department of the S. Maugeri Foundation early after cardiac surgery performed a 6-min walking test within the fourth day of hospital admission. Results: The mean walked distance was 296 111 m ( SD). At multiple regression analysis, age, sex, and comorbidity were independent predictors of walking test performance. The left ventricular ejection fraction only influenced the walked distance in men. Starting from these variables, we propose an algorithm and specific reference tables. Conclusions: Reference values for gender-, age-, comorbidity-, and systolic function-related test performance in patients after cardiac surgery at the beginning of the rehabilitative phase are provided. Once a new patient has been categorized through simple parameters, the actual distance walked could be compared with the matched reference value, thus making the interpretation of the result more efficient. The walked distance might be used to define different levels of disability and to personalize therapeutic exercise prescriptions. (CHEST 2004; 126:1796 1801)
Key words: cardiac surgery; rehabilitation; 6-min walking test Abbreviations: LVEF left ventricular ejection fraction; 6MWT 6-min walking test

oon after a cardiac surgery procedure, a patient is S prescribed an individual rehabilitation program based on his or her demographic, clinical, psychological, and functional variables.1 In this perspective, early execution of the 6-min walking test (6MWT) can be useful. The 6MWT is a practical, simple test, which requires only the ability to walk; its use can be
*From the Istituto di Ricovero e Cura a Carattere Scientifico Salvatore Maugeri Foundation, Cardiology Department (Drs. Opasich, De Feo, Furgi, Pedretti, Scrutinio, and Tramarin), Scientific Institute of Pavia, Pavia; and Department of Biomedical Engineering (Dr. Pinna), Scientific Institute of Montescano, Montescano, Italy. Manuscript received February 4, 2004; revision accepted July 13, 2004. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (e-mail: permissions@chestnet.org). Correspondence to: Cristina Opasich, MD, IRCCS Salvatore Maugeri Foundation, Cardiology Department, Via Ferrata 8, I-27100 Pavia; e-mail: copasich@fsm.it
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extended to frail and limited patients.2 The distance that a patient can walk on a flat surface in a period of 6 min may be used either as a generic one-time measure of functional status or as an outcome measure for the rehabilitation program. The results of the 6MWT are generally interpreted as a percentage of predicted values in healthy subjects.3 However, a correct interpretation of the 6MWT in a given patient can only be achieved by comparing that patients 6MWT performance with appropriate reference values for the specific population from which the patient comes: the higher the affinity of the patient with the reference population, the lower the risk of approximation in the interpretation. Thus, the aims of the present study were as follows: (1) to assess the descriptive parameters of 6MWT performance in a large sample of patients early after hospital admission to an intensive inhospital rehabilitation unit after cardiac surgery, (2)
Clinical Investigations

to investigate the influence of some relevant clinical and demographic variables on walking performance, and (3) to develop efficient reference tables for this population of patients based on a few easily measurable demographic and clinical indicators. These tables will be used for each patient at his/her entry to the cardiac rehabilitation program. Methods and Materials
Subjects Consecutive patients admitted between January 2001 and December 2002 to the Cardiac Rehabilitation Department of the Salvatore Maugeri Foundation (which includes seven in-hospital rehabilitation units) early after cardiac surgery were considered. Among these patients, those who performed a 6MWT within the fourth day of hospital admission were included in this study, the others being physically severely frail or presenting actual clinical contraindication to the exercise. The demographic and clinical variables of these patients were extracted from the database of the Cardiac Rehabilitation Department. The following data were considered in this study: age; sex; presence of comorbid conditions, such as chronic cerebrovascular disease, diabetes mellitus, renal failure (defined as a creatinine value 1.5 mg/dL), and COPD; left ventricular ejection fraction (LVEF), measured by echocardiography on admission to the rehabilitation units; number of atherosclerotic risk factors; and time between the index event and admission to the rehabilitation unit. In order to test the usefulness of reference tables in clinical practice, we also considered a new group of 567 consecutive patients admitted to our department after cardiac surgery. As for the main group, the 6MWT was performed in these patients within 4 days of hospital admission. At discharge from the hospital, the test was repeated and the time spent in the rehabilitation unit was recorded. 6MWT The 6MWT was performed according to the standardized procedure.4 The test was supervised by a physical therapist and was performed, if indicated by the physician, using telemetry monitoring. Subjects were asked to walk at their own maximal pace along a 35-m long, flat, and straight hospital corridor. No encouragement was offered. The test was symptom limited, so patients were allowed to stop if signs or symptoms of significant distress occurred (severe dyspnea, dizziness, angina, skeletal muscle pain), though they were instructed to resume walking as soon as possible. The distance covered during the test was recorded in meters. Statistical Analysis The associations between demographic and clinical variables and 6MWT performance were assessed by a Pearson coefficient of correlation or by analysis of variance with post hoc multiple comparisons (Scheffe test), depending on whether the variables were continuous or categorical, respectively. Variables found to be significant in univariate analysis were the further analyzed by a multivariate linear regression model in order to identify a set of variables independently associated with 6MWT performance. Besides main effects, we also tested for possible interaction effects between pairs of variables (eg, between LVEF and gender).
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Reference cross-tabulation tables for 6MWT performance were obtained by grouping the patients of the study according to the value of the variables selected by the multivariate model, and computing relevant 6MWT statistics (mean, SD, median, lower and upper quartiles) for each group. As some classification variables were continuous, they were first categorized into two or three levels. To test the practical usefulness of reference tables, we reasoned that patients with a poor 6MWT performance on admission to a postoperative in-hospital rehabilitation program would be less likely to recover. Accordingly, each patient enrolled in the new test group was classified as having poor or preserved 6MWT performance if the walked distance on program admission was, respectively, within or above the lowest quartile statistic reported in the reference tables for his/her specific combination of demographic and clinical variables. An analysis of variance was then carried out to determine the following: (1) whether patients with poor walking test performance on program admission stayed longer in the rehabilitation unit than did those with preserved performance, and (2) whether they had a persistently reduced performance at discharge. Data are reported as mean 1 SD, unless otherwise specified. All tests of hypothesis were carried out using 0.05 as the level of statistical significance.

Results Patients During the 2 years considered, 5,482 patients (mean age, 65.6 9 years; 72% male gender) were admitted for intensive in-hospital cardiac rehabilitation after a cardiac surgery procedure (bypass surgery, 73%; valvular surgery, 25%; other, 2%). Among them, 2,555 patients performed the 6MWT within 4 days of hospital admission and were included in this study. The clinical characteristics of the studied population are summarized in Table 1. Almost all patients were 70 years old and had ischemic heart disease. Moreover, 46% of patients had at least one comorbid condition. About one fourth of cases had systolic left ventricular dysfunction (LVEF 50%). Women had a significantly higher LVEF than did men (51.5 10% vs 49.8 12%; p 0.0005). 6MWT Performance During the test, the patients walked an average of 296 111 m (range, 15 to 630 m), which was 59.5 22% of their predicted values according to the regression equation proposed by Enright and Sherrill3 in healthy subjects. Figure 1 shows the distribution of the distance walked in the overall population. The distance walked in 6 min was significantly associated with gender (Table 2), age (r 0.35, p 0.001), and the presence of at least one comorbid condition (Table 2). LVEF was weakly but significantly correlated with the 6MWT result only in men (r 0.11, p 0.001). This was confirmed by a
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Table 1Clinical Characteristics of the Patients*

Characteristics Patients, No. Mean age, yr Women Ischemic heart disease History of myocardial infarction Valvular disease Chronic heart failure Comorbid conditions Chronic cerebrovascular disease Renal failure (serum creatinine 1.5 mg/dL) COPD Diabetes mellitus Risk factors, No. 2 risk factors Smoking Current Past Never LVEF, % Missing 50 50 Mean Time from index event, d Mean length of rehabilitation stay, d Data 2,555 64.6 10 674 (26) 1,746 (68) 938 (37) 192 (7.5) 218 (8.5) 495 (19) 159 (8) 98 (4) 613 (24) 1.8 1.3 1,357 (53) 676 (26) 1,352 (53) 527 (21) 592 (23) 1,282 (50) 681 (27) 51 12 10 8 18 16

Table 2Six-Minute Walking Distance Covered by Patients Grouped According to Sex, Age, Comorbidity, and LVEF*
Distance Walked, m Gender Male Female Age, yr 61 6170 70 Comorbidity No Yes LVEF 50% and 50% and LVEF 50% and 50% and 319.9 105.5 229.3 99.2 324.6 99.9 293.95 103.6 251.9 112.6 310.7 108.3 278.9 112.1 male gender male gender female gender female gender 331.6 107.9 316.9 94.9 232.9 102.9 231.2 86.4 p Value 0.0001 0.0001

0.0001

0.016

0.85

Derivation of Reference Tables In order to build reference tables for the considered population of patients, we categorized age into three classes ( 61 years, 61 to 70 years, and 70 years). LVEF was initially categorized into three classes ( 35%, 35 to 49%, and 50%), but there was no difference in the distance walked between the first two. Thus, LVEF was categorized into two classes ( 50% and 50%). The 6MWT performance according to these categories as well as to sex and comorbidity are reported in Table 2. The reference values for 6MWT performance in male subjects according to age, presence/absence of comorbidity, and LVEF are given in Table 3. The same descriptive statistics are given in Table 4 for female subjects according to age and presence/ absence of comorbidity. Testing the Usefulness of Reference Tables Of the 567 new patients enrolled for the validation study, 365 were men 202 were women. The mean age of these patients was 65.2 10 years (range, 23 to 87 years), and their mean LVEF was 54 12%. Patients with a poor 6MWT performance on program admission showed a significantly longer length of rehabilitation stay than did patients with preserved performance, and they also had significant persistent functional impairment at program discharge (Table 5). Of note, the mean distance walked in 6 min at program discharge by patients with poor performance at the beginning of the rehabilitation program was very close to the mean distance covered at program admission by patients with preserved performance.
Clinical Investigations

*Data are presented as mean SD or No. (%) unless otherwise indicated.

significant interaction between gender and LVEF in the multiple linear regression model (p 0.006). Age and comorbidity were independently associated with 6-min walking performance (p 0.001 for both). LVEF was entered in the multivariate model as a further independent predictor in men (p 0.001). The 6MWT performance did not correlate with the timing distance between surgery and the day of the test (which could be influenced by the surgical complications).

Figure 1. Frequency (N) distribution of the 6MWT results in the overall population (n 2,555).
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Table 3References Values in Men Stratified by Age, LVEF, and Comorbidity

Age, yr 60 Comorbidities Absent Mean SD Median Lower quartile Upper quartile Present Mean SD Median Lower quartile Upper quartile LVEF 50% n 205 369 92 370 310 427 n 109 346 102 350 292 416 LVEF 50% n 119 360 90 360 310 420 n 63 341 89 344 282 400 LVEF 50% n 191 330 98 340 260 400 n 156 326 109 334 250 400 6170 LVEF 50% n 108 302 101 309 241 377 n 105 282 100 286 220 360 LVEF 50% n 113 310 113 300 220 390 n 124 287 122 284 200 371 71 LVEF 50% n 79 268 102 270 180 340 n 85 254 119 248 175 325

Discussion In the last years, the 6MWT has become one of the most popular clinical exercise test for evaluating functional capacity. It is a practical, simple, and inexpensive test, and does not require any exercise equipment or advanced training for technicians.4 The test has close similarities to activities of daily living and can be performed by many elderly, frail, and severely limited patients who could not be evaluated by standard maximal symptom-limited exercise tests, as are cardiac patients after recent major surgery. The test is widely employed in cardiac rehabilitation in various categories of patients (after cardiac surgery, after myocardial infarction, chronic heart failure), both as a functional status indicator and as an outcome measure.510 In our previous experience with elderly patients after cardiac surgery, the 6MWT performed within the first week of hospital admission for rehabilitation was feasible and safe.2 The timing of the test and the walking performance were strongly influenced by the patients disability and dependence level, assessed by nursing needs. Moreover, the walking

Table 4 References Values in Women Stratified by Age and Comorbidity

Age, yr Comorbidity Absent Mean SD Median Lower quartile Upper quartile Present Mean SD Median Lower quartile Upper quartile 60 (n 75) 283 96 295 210 350 (n 83) 267 100 275 200 340 6170 (n 101) 255 93 249 200 318 (n 151) 220 86 220 160 280 71 (n 115) 184 83 178 125 240 (n 149) 207 105 200 132 280

capacity affected the patients self-perceived heath status and identified more severely compromised patients with lower susceptibility to recovery.1,2 In the database, the reasons why the walking test was not performed within the forth day were not categorized; consequently, we could not speculate on the possible clinical differences between patients who did and those who did not perform the test. The present study assessed the descriptive parameters of a 6MWT carried out by a large sample of patients early after admission to an intensive inhospital rehabilitation unit after cardiac surgery, and investigated the influence of some clinical and demographic variables on the tested walking performance. Moreover, the huge number of patients in this study offered us the chance to construct reference tables developed in this specific population. A correct interpretation of the 6MWT in any given patient can only be achieved using reference values with the highest affinity in terms of selected population. The reference tables have been built up taking into account the variables that independently affected the distance walked. Thus, in order to interpret the distance walked by a new similar patient correctly, we propose that this value is compared with a specific reference value for that type of patient obtained from an easy and quick-touse algorithm based on few common clinical data. First, we suggest that the patient is characterized according to his or her demographic variables. In fact, the present study confirmed the influence of sex and age on the walking performance of patients after cardiac surgery: the distance walked was greater in men than women and was inversely related to age. Several studies3,1118 have already reported that functional capacity is affected by such demographic variables, with performance decreasing in older patients and in women. The gradual reduction of skeletal muscle mass and strength that generally
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Table 5Duration of Rehabilitation Stay and 6-min Walked Distance on Hospital Admission and Discharge for the Patients in the Test Group (n 567)*
Poor 6MWT Performance (n 260) Variables Walked distance, m Duration of stay, d Admission 168.05 85 17.7 6.7 Discharge 322.7 126 Preserved 6MWT Performance (n 307) Admission 329.6 83 14.2 5.3 Discharge 416 98

*Data are presented as mean SD. Patients were classified as having poor or preserved 6-min walking performance if the walked distance on admission was, respectively, within or above the lower quartile statistic reported in reference Tables 3 and 4. p 0.001 compared to patients with preserved 6MWT. p 0.001 compared to patients with preserved 6MWT.

occurs with aging and the increasing prevalence of debilitating diseases are probably responsible for the shorter distance walked in elderly patients. Moreover, women show lower functional capacity with respect to men independently of differences in age, depression score, or frequency of comorbidity.9,14 Subsequently, the presence of comorbidity should be assessed. The prevalence of comorbid conditions is high among patients admitted for in-hospital cardiac rehabilitation intervention after surgery, and indeed cardiac surgery is being ever increasingly offered as a therapeutic option for elderly, frail patients. Performance of the 6MWT is poor in patients with many chronic diseases, such as osteoarthritis, pulmonary, vascular, neurologic, and muscular diseases. In these settings, the test is widely used as a measure of exercise capacity.19 25 In this study, we considered comorbid conditions that are known or believed to affect the results of the test: diabetes mellitus, present in almost one quarter of the entire population; renal failure; chronic cerebrovascular diseases; and COPD. The symptomatic peripheral occlusive arterial disease was considered as exclusion criteria for the 6MWT. In our population, the presence of one or more comorbid conditions negatively affected the walking performance, independently of sex and age. As the final step of the proposed algorithm, left ventricular systolic function should be assessed, but considered only for men. In fact, in our study, this parameter was independently associated with the distance walked in men (possibly explained by physical deconditioning in patients with left ventricular dysfunction), but there was a significant interference between female sex and left ventricular fraction. It is possible that the usually higher values of LVEF in women, confirmed in our population, negatively affected the correlation. Thus, appropriate reference values for interpreting the walking performance of a new patient should be selected in function of the patients gender, age, comorbidity, and left ventricular function (Fig 2).
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Once the patient has been categorized, the distance walked can be compared with his/her matched reference value, and the interpretation of the result becomes more efficient. For instance, we tested the contribution of the proposed algorithm in a sample of 500 consecutive patients. Half of them walked a shorter distance than the distances in the lowest quartile of their respective reference tables. In these patients, the functional impairment on admission into the intensive rehabilitation programs reflected a greater nursing need, correlated with a longer time spent in the rehabilitation unit, and negatively influenced the functional recovery achieved by the end of the rehabilitation phase. These patients might benefit from more specific and longer rehabilitation programs. Conclusions In order to interpret the results of the 6MWT more accurately in any single patient after cardiac surgery, we propose the use of an easy algorithm and comparison with an appropriate reference table de-

Figure 2. Suggested algorithm for an efficient use of the walking test in the individual patient early after cardiac surgery.
Clinical Investigations

rived from a similar population. The degree of physical impairment, assessed early after admission to an in-hospital cardiac rehabilitation unit, can be used both to assess the care and nursing needs of the patient and in the perspective of prescribing a personalized intensive rehabilitation program.
ACKNOWLEDGMENT: We thank the therapists and technicians of the Cardiologic Department of the Salvatore Maugeri Foundation for making this study possible: Cassano: Amelia Mancini, Walter Monaco, Florinda Minerva; Gussago: Daniela Voltolini, Monica Benzoni, Ciro Rangioletti; Pavia: Antonio Mazza, Federica Camera, Antonella Maestri; Montescano: Agostina Civardi, Angela Lupo, Giulia Salvaneschi, Anna Maria Ventura, Milena Scabini, Patrizia Leonelli, Alessandra Pitocchi; Telese: Maria Giovanna Beatrice, Ivana De Pierro, Silvana Ievolella, Maria Gabriella Porcaro; Tradate: Mario Pribetich, Eleonora Milani, Laura Gracilla; Veruno: Alfio Agazzone, Elena Bonanomi. Moreover, we acknowledge D. Brovelli and P. Vaghi for support with informatics.

References
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