World J Surg (2015) 39:1406–1412

DOI 10.1007/s00268-015-2961-4

ORIGINAL SCIENTIFIC REPORT

The SF-36 and 6-Minute Walk Test are Significant Predictors

of Complications After Major Surgery
Haitham Awdeh • Kassem Kassak •
Pierre Sfeir • Hadi Hatoum • Hala Bitar •

Ahmad Husari

Published online: 5 February 2015

Ó Société Internationale de Chirurgie 2015

Abstract
Background Major surgeries are associated with postoperative morbidity and mortality. Current preoperative
evaluation fails to identify patients at increased risk of postoperative complications. This study is aimed to determine
whether the Short Form-36 health survey (SF-36) and the 6-minute walk test (6-MWT) are useful predictors of
postoperative complications after major surgery.
Methods All patients scheduled to undergo major surgery were eligible for the study. Major surgeries include
patients undergoing thoracotomy, sternotomy, or upper abdominal laparotomy. The SF-36 health survey and 6-MWT
were administered prior to surgery. Spirometry and other preoperative testing, ordered by the surgeon, like echo-
cardiography were included in the study. Patients were then followed-up for postoperative complications for 30 days.
Results One-hundred and seventeen subjects undergoing major surgery were recruited to the study. The mean age
was 58 years and 66 (56.4 %) were male. Physical Functioning as a component of the SF-36 positively correlated
with decreased length of hospital stay (LOS). The 6-MWT had a negative correlation with LOS (p \ 0.0001) and
with severity of postoperative complications (p \ 0.0001). Spirometry and echocardiography did not correlate with
LOS or grade of complications.
Conclusions SF-36 (Physical Functioning) and 6-MWT are useful indicators for predicting postoperative com-
plications and LOS.
Condensed abstract Patients undergoing major surgery answered SF-36 and performed 6-MWT. Physical Func-
tioning as a component of the SF-36 correlated with LOS. The 6-MWT had a negative correlation with LOS and with
complication grade. SF-36 and 6-MWT are useful predictors of postoperative complications.

H. Awdeh
H. Hatoum
H. Bitar
A. Husari (&)
Division of Pulmonary and Critical Care Medicine, Department
of Internal Medicine, American University of Beirut Medical
Center, P.O. Box: 113-6044, Beirut 1107 2802, Lebanon
e-mail: ah51@aub.edu.lb
K. Kassak
Department of Health Management and Policy, American
University of Beirut Medical Center,
P.O. Box: 113-6044, Beirut 1107 2802, Lebanon
P. Sfeir
Division of Cardiothoracic Surgery, Department of Surgery,
American University of Beirut Medical Center,
P.O. Box: 113-6044, Beirut 1107 2802, Lebanon
Introduction
More than 200 million major surgeries are performed every
year worldwide [1]. Patients undergoing major cardiotho-
racic and abdominal surgery are at risk of developing
postoperative complications requiring prolonged hospital
stays and substantial resources [2, 3]. Identifying patients
at high risk of complications may guide clinical decision
making or aid in planning postoperative resource allocation
[4, 5]. Several tools, including the Short Form-36 health
survey (SF-36) and the 6-minute walk test (6-MWT),
evaluate the functional status of patients and may predict
their risk of postoperative complications [6, 7].

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The SF-36 is a survey instrument used to measure health
status and quality of life in medical outcome studies [8].
The questionnaire addresses two major components:
Physical Functioning and Mental Health. In Sheffield, UK,
the reliability of SF-36 was rigorously tested and validated
[9]. The 6-MWT is a reproducible, safe, simple, and
inexpensive test that can be used to evaluate exercise [10].
6-MWT is used to estimate functional capacity in patients
with a variety of medical conditions and can be performed
by those who are unable or unwilling to undertake formal
treadmill or bicycle exercise tests [11–15].
This study examined whether preoperative SF-36 ques-
tionnaire and 6-MWT are useful predictors of postopera-
tive complications. The study also evaluated the usefulness
of preoperative testing performed at community hospitals
(spirometry and echocardiography) as compared to the
results obtained from the SF-36 and the 6-MWT.
Materials and methods
Ethics
This study was conducted at the American University of
Beirut Medical Center (AUBMC). The institutional review
board at AUBMC approved this longitudinal prospective
study. Written informed consent was obtained from all
study subjects before enrollment.
Inclusion and enrollment
All patients scheduled to undergo major surgery were
solicited to participate in the study. The patient would then
undergo SF-36, 6-MWT, and spirometry. Echocardiography
was performed when requested by the consultant physicians.
Major surgery included thoracotomy, sternotomy, or upper
abdominal laparotomy [4]. Surgery decision was based on
the preoperative assessment and no patient was denied sur-
gery on the basis of enrollment in our study. In addition, the
study did not interfere with the routine preoperative prepa-
ration by surgeons including the use of incentive spirometry,
thromboembolic and antibiotic prophylaxis, appropriate
monitoring, etc. The study was initiated in 2006; collection
and analysis of data were concluded in 2011.
Testing
The Short Form (36) health survey (SF-36)
SF-36 was administered prior to the 6-MWT and as doc-
umented in the literature (see Table 3 Appendix) [14, 15].
It has 36 multi-item scale self-administered questions
addressing eight health concepts: Physical Functioning,
1407
Social Functioning, Emotional Role Functioning, Emo-
tional Physical Functioning, General Mental Health,
Vitality, Bodily Pain, and General Health Status.
Six-minute walk test (6-MWT)
The 6-MWT was performed according to the guidelines of
the American Thoracic Society (ATS) [12]. The patient’s
gender, height, weight, and medications were documented at
the beginning of the test. Heart rate, blood pressure, dyspnea,
fatigue, and SpO2 were measured at baseline and at the end of
the test. Assessment of dyspnea and fatigue were measured
using the Borg scale (see table 4 Appendix) [16].
Patients were required to walk as far as possible in
6 min along a 30-meter flat corridor, turning 180° every
30 m. The walk test was timed and the time was called out
every 2 min. The patient was encouraged with standard
phrases as stated in the ATS protocol. Patients were
allowed to rest but were instructed to carry on walking as
soon as they were able to do so. After 6 min had elapsed,
patients were instructed to stop walking and the total dis-
tance was measured.
Spirometry
Spirometry was measured via Koko spirometer (PDS
Ferraris, Louisville, CO, USA). Forced expiratory volume
in one second (FEV1) and forced vital capacity (FVC) were
determined from the best of three efforts.
Echocardiography
Some patients, based upon the recommendation of the
consultant cardiologist, underwent a comprehensive trans-
thoracic echocardiogram at baseline (Hewlett-Packard
Sonos 5500, Philips, Andover, MA, USA). Left ventricular
ejection fraction (LVEF) was measured using Simpson’s
biplane method [17]. Any valve abnormality was noted.
Pulmonary artery pressure was measured when technically
feasible.
Outcome measurement
Postoperative complications were defined as follows: ST
segment elevation myocardial infarction (positive ECG
changes with elevated cardiac isoenzymes); non-ST seg-
ment elevation myocardial infarction (elevated cardiac
isoenzymes with no ECG changes); hospital onset unstable
angina; congestive heart failure (rales on physical exami-
nation and chest radiograph showing pulmonary edema
with pulmonary capillary wedge pressure, if available, of
[18 mm Hg, or clinical response to diuretics); arrhythmia
requiring therapy, re-intubation, or prolonged mechanical
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ventilation ([48 h after surgery); pneumonia (a tempera-
ture of [38 °C for [48 h without an identifiable non-pul-
monary source, plus purulent sputum and an infiltrate seen
on chest radiograph); lobar atelectasis (seen on a chest
film) requiring medical or bronchoscopic intervention;
elevated PaCO2 ([50 or [10 mm Hg over the baseline
lasting for [48 h after surgery); pulmonary embolism (a
high probability for ventilation–perfusion scanning or
abnormal CT pulmonary arteriogram); urinary tract infec-
tion; sepsis (hypothermia or hyperthermia, bacteremia, and
hypotension); and death. Patients were followed-up to
30 days after surgery. The grading of surgical complica-
tions was done on a scale from I to V based on the work
published by Dindo et al. (see table 5 in Appendix) [18].
Data management
Research assistants administered the questionnaire, per-
formed spirometery on all patients, and charted the data.
6-MWT was administered by a physician with the assis-
tance of an RA. Collected clinical data were utilized to
assess patients’ comorbid conditions by calculating
Charlson Comorbidity Index as described before [19].
Data analysis
Analysis of Variance (ANOVA) was used to test associa-
tions at a 95 % confidence interval. ANOVA was also used
to test the results of 6-MWT with the postoperative out-
come measures. Linear regression analysis was used to
predict the LOS as a continuous dependent variable, and to
test the association with 6-MWT and SF-36. The coeffi-
cient of determination was used to indicate the percentage
of the variance in the dependent variable that was
explained by the independent variables.
Results
One-hundred and sixty-five patients were solicited to par-
ticipate in the study and one-hundred and nineteen agreed
to proceed. Two patients were not able to perform 6-MWT
and were subsequently excluded from the study (Fig. 1).
One-hundred and seventeen subjects were enrolled and
completed the study requirements. The mean age was
58 years (range 18–82 years) and 66 (56.4 %) were male.
Charlson Comorbidity Index (CCI) was 3.55 (SD = 2.10).
The mean score of Physical Functioning component (SF
36) was 78.25 (range 0–100) and of Social Functioning (SF
36) was 76.07 (range 0–100). The mean distance walked on
the 6-MWT was 3.18.0 m (range 0–549 m). Baseline
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World J Surg (2015) 39:1406–1412
characteristics of the study population are summarized in
Table 1. Spirometry was done on all patients however,
only 55 patients did echocardiography as recommended by
the cardiologist. At the end of follow-up, 7 (6 %) patients
had grade I, 20 (17.0 %) grade II, 6 (5.1 %) grade III, 10
(8.5 %) grade IV, and 5 (4.2 %) had grade V postoperative
complications (Fig. 1).
We defined the increase in the length of hospital stay
(LOS) as the difference between the real hospital stay and
the expected hospital stay divided by the expected hospital
stay. The median postoperative LOS was 7.7 days (range
1–57 days). Age and duration of anesthesia did not corre-
late with the LOS and grade of complications in patients
undergoing major surgery (Table 2). Physical Functioning
correlated the highest with LOS in this group. The 6-MWT
had a negative correlation with LOS (Pearson correlation
-0.286; p \ 0.002). Role Limitations, Mental Health, and
Vitality also correlated with LOS (Pearson correlation
-0.236; p \ 0.013), (Pearson correlation -0.264;
p \ 0.005), and (Pearson correlation -0.228; p \ 0.016),
respectively. Spirometry and echocardiography did not
associate with LOS too (Table 2). When complications
were looked at, neither the SF-36 nor its components cor-
related with grade of complications. The 6-MWT distance
demonstrated significant correlation with complication
grade (Fig. 2). Linear regression showed that 6-MWT
distance explains 31.8 % of the variance in complications
(Pearson correlation -0.564; p \ 0.0001). In patients who
underwent coronary artery bypass grafting (CABG), linear
regression showed that the 6-MWT explains 29.6 % of the
variance in the grade of complications (p = 0.02) and the
SF-36 explains 21 % of the variance in LOS (p = 0.005).
On the basis of distance walked during the 6-MWT,
patients were divided into two groups: B300 m (Group 1,
n = 40) and [300 m (Group 2, n = 74). The mean LOS
for Groups 1 and 2 was 9.82 and 7.22 days, respectively
(p = 0.05).
Discussion
The study aimed to assess the usefulness of SF-36 and
6-MWT obtained prior to surgery in predicting postoper-
ative complications and outcome. We showed that the
Physical Functioning component of the SF-36 had the
highest correlation with LOS. As for the 6-MWT, the study
showed that 6-MWT had a negative correlation with
postoperative complications. Commonly performed testing
like spirometry and echocardiography did not predict the
grade of complications or LOS. Our study also showed that
a 6-MWT distance B300 m is associated with a sharp
World J Surg (2015) 39:1406–1412 1409

165 patients were solicited to

participate in the study

49 declined to
participate

2 patients could not

perform 6-MWT

117 patients enrolled

in the study

Complications Number of patients

Blood transfusions 8
Types and number of surgeries performed Number of patients
Death 5
Coronary artery bypass graft surgery 32
Bacteremia / sepsis 4 Laparoscopic gastric bypass surgery( BMI > 35)* 11
Urinary tract infection 4 Pneumonectomy 7
Hypotension requiring intervention 4 Hepatectomy 6
Congestive heart failure 4 Colectomy 6
Abdominal aortic aneurysm repair 5
Atrial or ventricular Fibrillation 5
Aortic valve replacement 5
Pneumonia 4
Gastrectomy 4
Cerebrovascular accident 3 Debulking abdominal tumor 3
ICU admission 3 Whipple procedure 3
Active bleeding requiring intervention 3 Adrenalectomy 2
Pleural effusion 2 Excision of retroperitoneal mass 2

Acute renal failure 2 Others 31

Other 9

Fig. 1 Study enrollment, number, types of surgeries, and complications of patients undergoing major surgery

Table 1 Clinical characteristics of the patients LOS and necessitate additional human and financial
recourses [2–4]. Therefore, anticipating these resources
Number 117
with simple, low-cost techniques that can be implemented
Agea (years) 57.7 ± 13.8 in resource-limited settings is important. Several modalities
Male (%) 66 (56.4) are available to determine whether patients are at a con-
Charlson Comorbidity Indexa 3.55 ± 2.10 siderable risk for postoperative complications [20–22].
Physical Functioning (SF 36)a 78.25 ± 23 The determination of mental and physical health status
Social Functioning (SF 36)a 76.07 ± 34 has been utilized to assess quality of life in many clinical
6-MWT distancea (meters) 318.0 ± 120.6 and surgical conditions [13, 23–25]. Donkers et al. docu-
Echocardiography scorea 1.57 ± 0.94 mented close association between preoperative question-
Spirometery scorea 1.38 ± 0.65 naires assessing the physical activity of patients and
Length of hospital staya (days) 7.70 ± 6.14 objective measurements of physical fitness suggesting that
a
questionnaires can be utilized to assess physical fitness and
Values are expressed as mean ± SD
to predict postoperative outcomes [26]. Exercise capacity
increase in postoperative complications and in a longer as part of the assessment of preoperative risk has been
LOS. performed using the 6-MWT, cycle ergometry with
In addition to the morbidity and mortality associated assessment of oxygen uptake, and stair climbing [27]. The
with major surgery, postoperative complications increase literature, however, is deficient in standardized methods of

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Table 2 Correlations of the 6-MWT and SF-36 with grade of complications and length of stay
Grade of complications p value LOS p value

Age N 117 113

Pearson correlation 0.144 0.127 0.124 0.145
Duration of anesthesia N 117 113
Pearson correlation 0.110 0.245 0.038 0.689
6-MWT N 117 113
Pearson correlation -0.536 0 -0.284 0.0002
Physical functioning (SF-36) N 117 113
Pearson correlation -0.148 0.11 -0.295 0.002
Social functioning (SF-36) N 117 113
Pearson correlation -0.039 0.677 -0.188 0.047
Spirometry N 117 113
Pearson correlation -0.5 0.606 0.029 0.768
Echocardiography N 55 113
Pearson correlation 0.102 0.469 0.33 0.017
LOS length of stay

Fig. 2 6-MWT distance (6- 400

MWD) in meters and
complication grade in patients
undergoing major surgery 350

300
6MWD (M)

250

200

150

100
No complicaon Abnormal Medical Surgical Life threatening Death
findings /no Intervenon Intervenon
intervenon
Complication Grade

preoperatively assessing morbidities and postoperative capacity (6-MWT). The study noted the added value of
complications [28, 29]. obtaining both tests preoperatively in patients undergoing
This study combined results from preoperative testing of major surgery. The study is limited by the fact that not all
mental and physical health status (SF-36) and exercise patients underwent echocardiography to accurately assess

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its clinical validity in screening patients for postoperative Table 4 The Borg scale
complications in this study. Another shortcoming is the Nothing at all 0
relatively small number of patients who developed post- Very, very light 0.5
operative complications, which restricts the study power Light 1
and limits the identification of potential confounding Fairly light 2
variables. Moderate 3
Somewhat heavy 4
Heavy 5
Conclusion
6
Very heavy 7
The results from this study links the patient’s physical
8
functioning with LOS. The study also suggests that the
9
6-MWT is an effective tool that may be utilized to assess
Very, very heavy 10
clinical outcomes and postoperative complications in
patients undergoing major surgery. SF-36 and 6-MWT
could be considered as part of risk stratification in surgical
patients. The study warrants further investigations and
larger studies to establish the utility of the SF-36 and Table 5 Classification of surgical complications
6-MWT as good predictors of postoperative morbidity in
Grade Definition
patients undergoing major surgery.
Grade I Any deviation from the normal postoperative course
without the need for pharmacological treatment or
surgical, endoscopic, and radiological interventions
Funding This work was funded by the Medical Practice Plan and Allowed therapeutic regimens are: drugs as antiemetics,
the University Research Board at the American University of Beirut. antipyretics, analgetics, diuretics, electrolytes, and
physiotherapy. This grade also includes wound
infections opened at the bedside
Appendix Grade II Requiring pharmacological treatment with drugs other
than such allowed for grade I complications
See Tables 3, 4, and 5 in Appendix. Blood transfusions and total parenteral nutrition are also
included
Grade Requiring surgical, endoscopic, or radiological
III intervention
Grade Intervention not under general anesthesia
IIIa
Table 3 Dimensions of the SF-36 health survey Grade Intervention under general anesthesia
Area Dimension No. of IIIb
questions Grade Life-threatening complication (including CNS
IV complications)a requiring IC/ICU management
Functional status Physical functioning 10
Grade Single-organ dysfunction (including dialysis)
Social functioning 2 IVa
Role limitations (physical 4 Grade Mult-iorgan dysfunction
problems) IVb
Role limitations (emotional 3 Grade V Death of a patient
problems) Suffix If the patient suffers from a complication at the time of
Wellbeing Mental health 5 ‘‘d’’ discharge (see examples in Table 2), the suffix ‘‘d’’ (for
Vitality 4 ‘‘disability’’) is added to the respective grade of
Pain 2 complication. This label indicates the need for a follow-
up to fully evaluate the complication.
Overall evaluation of General health perception 5
health Health changea 1 CNS central nervous system, IC intermediate care, ICU intensive care
unit
Total 36 a
Brain hemorrhage, ischemic stroke, subarachnoidal bleeding, but
a
This item is not included in the eight dimensions nor is it scored excluding transient ischemic attacks

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References
1. Weiser TG, Regenbogen SE, Thompson KD, Haynes AB, Lipsitz
SR, Berry WR, Gawande AA (2008) An estimation of the global
volume of surgery: a modelling strategy based on available data.
Lancet 372:139–144
2. Lawrence VA, Hilsenbeck SG, Mulrow CD, Dhanda R, Sapp J,
Page CP (1995) Incidence and hospital stay for cardiac and
pulmonary complications after abdominal surgery. J Gen Intern
Med 10:671–678
3. Ginsberg RJ, Hill LD, Eagan RT, Thomas P, Mountain CF,
Deslauriers J et al (1983) Modern thirty-day operative mortality
for surgical resections in lung cancer. J Thorac Cardiovasc Surg
86:654–658
4. Girish M, Trayner E Jr, Dammann O, Pinto-Plata V, Celli B
(2001) Symptom-limited stair climbing as a predictor of post-
operative cardiopulmonary complications after high-risk surgery.
Chest 120:1147–1151
5. Chang JK, Calligaro KD, Lombardi JP, Dougherty MJ (2003)
Factors that predict prolonged length of stay after aortic surgery.
J Vasc Surg 38:335–339
6. Rasekaba T, Lee AL, Naughton MT, Williams TJ, Holland AE
(2009) The six-minute walk test: a useful metric for the cardio-
pulmonary patient. Intern Med J 39:495–501
7. Kiebzak GM, Pierson LM, Campbell M, Cook JW (2002) Use of
the SF36 general health status survey to document health-related
quality of life in patients with coronary artery disease: effect of
disease and response to coronary artery bypass graft surgery.
Heart Lung 31:207–213
8. Berwick DM (1991) The double edge of knowledge. JAMA
266:841–842
9. Brazier JE, Harper R, Jones NM, O’Cathain A, Thomas KJ,
Usherwood T et al (1992) Validating the SF-36 health survey
questionnaire: new outcome measure for primary care. BMJ
305:160–164
10. Cahalin LP, Mathier MA, Semigran MJ, Dec GW, DiSalvo TG
(1996) The six-minute walk test predicts peak oxygen uptake and
survival in patients with advanced heart failure. Chest
110:325–332
11. Woo MA, Moser DK, Stevenson LW, Stevenson WG (1997) Six-
minute walk test and heart rate variability: lack of association in
advanced stages of heart failure. Am J Crit Care 6:348–354
12. Guyatt GH, Sullivan MJ, Thompson PJ, Fallen EL, Pugsley SO,
Taylor DW et al (1985) The 6-minute walk: a new measure of
exercise capacity in patients with chronic heart failure. Can Med
Assoc J 132:919–923
13. Wise RA, Brown CD (2005) Minimal clinically important dif-
ferences in the six-minute walk test and the incremental shuttle
walking test. COPD 2:125–129
14. ATS Committee on Proficiency Standards for Clinical Pulmonary
Function Laboratories (2002) ATS statement: guidelines for the
six-minute walk test. Am J Respir Crit Care Med 166:111–117
123
World J Surg (2015) 39:1406–1412
15. Borg GA (1982) Psychophysical bases of perceived exertion.
Med Sci Sports Exerc 14:377–381
16. Schiller NB, Shah PM, Crawford M, DeMaria A, Devereux R,
Feigenbaum H et al (1989) Recommendations for quantitation of
the left ventricle by two-dimensional echocardiography. Ameri-
can Society of Echocardiography Committee on Standards,
Subcommittee on Quantitation of Two-Dimensional Echocar-
diograms. J Am Soc Echocardiogr 2:358–367
17. Dindo D, Demartines N, Clavien PA (2004) Classification of
surgical complications: a new proposal with evaluation in a
cohort of 6336 patients and results of a survey. Ann Surg
240:205–213
18. Charlson ME, Pompei P, Ales KL, MacKenzie CR (1987) A new
method of classifying prognostic comorbidity in longitudinal
studies: development and validation. J Chronic Dis 40:373–383
19. Schäfer JH, Maurer A, Jochimsen F, Emde C, Wegscheider K,
Arntz HR et al (1990) Outcome prediction models on admission
in a medical intensive care unit: do they predict individual out-
come? Crit Care Med 18:1111–1118
20. Ryan TA, Rady MY, Bashour CA, Leventhal M, Lytle B, Starr
NJ (1997) Predictors of outcome in cardiac surgical patients with
prolonged intensive care stay. Chest 112:1035–1042
21. Asimakopoulos G, Al-Ruzzeh S, Ambler G, Omar RZ, Punjabi P,
Amrani M et al (2003) An evaluation of existing risk stratification
models as a tool for comparison of surgical performances for
coronary artery bypass grafting between institutions. Eur J Car-
diothorac Surg 23:935–941
22. McCarthy MJ Jr, Shroyer AL, Sethi GK, Moritz TE, Henderson
WG, Grover FL et al (1995) Self-report measures for assessing
treatment outcomes in cardiac surgery patients. Med Care
33:OS76–OS85
23. Matsen FA 3rd, Ziegler DW, DeBartolo SE (1995) Patient self-
assessment of health status and function in glenohumeral
degenerative joint disease. J Shoulder Elbow Surg 4:345–351
24. Adler DA, Bungay KM, Cynn DJ, Kosinski M (2000) Patient-
based health status assessments in an outpatient psychiatry set-
ting. Psychiatr Serv 51:341–348
25. Arnberger M, Vogt A, Studer P, Inderbitzin D, Pulver C, Röhrig
B et al (2009) Evaluation of physical and mental recovery status
after elective liver resection. Eur J Anaesthesiol 26:559–565
26. Dronkers JJ, Chorus AM, van Meeteren NL, Hopman-Rock M
(2013) The association of pre-operative physical fitness and
physical activity with outcome after scheduled major abdominal
surgery. Anaesthesia 68:67–73
27. Holden DA, Rice TW, Stelmach K, Meeker DP (1992) Exercise
testing, 6-min walk, and stair climb in the evaluation of patients
at major for pulmonary resection. Chest 102:1774–1779
28. Kertai MD, Klein J, Bax JJ, Poldermans D (2005) Predicting
perioperative cardiac risk. Prog Cardiovasc Dis 47:240–257
29. Potyk DK (1994) Cardiac evaluation and risk reduction in
patients undergoing major vascular operations. West J Med
161:50–56