Comment

. 2019 Aug;123(2):161-169.

doi: 10.1016/j.bja.2019.04.058. Epub 2019 Jun 19.

Association of preoperative anaemia with cardiopulmonary exercise capacity and postoperative outcomes in noncardiac surgery: a substudy of the Measurement of Exercise Tolerance before Surgery (METS) Study

J Bartoszko¹, K E Thorpe², A Laupacis³, D N Wijeysundera⁴; METS Study Investigators; International and National Coordinators; Central Project Office Operations Committee; CPET Methods Committee; Outcome Adjudication Committee; International Steering Committee

Collaborators, Affiliations

Collaborators

P S Myles⁵, M A Shulman⁵, S Wallace⁵, C Farrington⁵, B Thompson⁵, M Ellis⁵, B Borg⁵, R K Kerridge⁶, J Douglas⁶, J Brannan⁶, J Pretto⁶, M G Godsall⁷, N Beauchamp⁷, S Allen⁷, A Kennedy⁷, E Wright⁷, J Malherbe⁷, H Ismail⁸, B Riedel⁸, A Melville⁸, H Sivakumar⁸, A Murmane⁸, K Kenchington⁸, Y Kirabiyik⁸, U Gurunathan⁹, C Stonell⁹, K Brunello⁹, K Steele⁹, O Tronstad⁹, P Masel⁹, A Dent⁹, E Smith⁹, A Bodger⁹, M Abolfathi⁹, P Sivalingam¹⁰, A Hall¹⁰, T W Painter¹¹, S Macklin¹¹, A Elliott¹¹, A M Carrera¹¹, N C S Terblanche¹², S Pitt¹², J Samuels¹², C Wilde¹², K Leslie¹³, A MacCormick¹³, D Bramley¹⁴, A M Southcott¹⁴, J Grant¹⁴, H Taylor¹⁴, S Bates¹⁴, M Towns¹⁴, A Tippett¹⁴, F Marshall¹⁴, C D Mazer¹⁵, J Kunasingam¹⁵, A Yagnik¹⁵, C Crescini¹⁵, S Yagnik¹⁵, C J L McCartney¹⁶, S Choi¹⁶, P Somascanthan¹⁶, K Flores¹⁶, D N Wijeysundera¹⁷, W S Beattie¹⁷, K Karkouti¹⁷, H A Clarke¹⁷, A Jerath¹⁷, S A McCluskey¹⁷, M Wasowicz¹⁷, J T Granton¹⁷, L Day¹⁷, J Pazmino-Canizares¹⁷, P Oh¹⁸, R Belliard¹⁸, L Lee¹⁸, K Dobson¹⁸, V Chan¹⁹, R Brull¹⁹, N Ami¹⁹, M Stanbrook¹⁹, K Hagen²⁰, D Campbell²⁰, T Short²⁰, J Van Der Westhuizen²⁰, K Higgie²⁰, H Lindsay²⁰, R Jang²⁰, C Wong²⁰, D Mcallister²⁰, M Ali²⁰, J Kumar²⁰, E Waymouth²⁰, C Kim²⁰, J Dimech²¹, M Lorimer²¹, J Tai²¹, R Miller²¹, R Sara²¹, A Collingwood²¹, S Olliff²¹, S Gabriel²¹, H Houston²¹, P Dalley²², S Hurford²², A Hunt²², L Andrews²², L Navarra²², A Jason-Smith²², H Thompson²², N McMillan²², G Back²², B L Croal²³, M Lum²³, D Martin²⁴, S James²⁴, H Filipe²⁴, M Pinto²⁴, S Kynaston²⁴, R M Pearse²⁵, T E F Abbott²⁵, M Phull²⁵, C Beilstein²⁵, P Bodger²⁵, K Everingham²⁵, Y Hu, E Niebrzegowska²⁵, C Corriea²⁵, T Creary²⁵, M Januszewska²⁵, T Ahmad²⁵, J Whalley²⁵, R Haslop²⁵, J McNeil²⁵, A Brown²⁵, N MacDonald²⁵, M Pakats²⁵, K Greaves²⁵, S Jhanji²⁶, R Raobaikady²⁶, E Black²⁶, M Rooms²⁶, H Lawrence²⁶, M Koutra²⁶, K Pirie²⁶, M Gertsman²⁶, S Jack²⁷, M Celinski²⁷, D Levett²⁷, M Edwards²⁷, K Salmon²⁷, C Bolger²⁷, L Loughney²⁷, L Seaward²⁷, H Collins²⁷, B Tyrell²⁷, N Tantony²⁷, K Golder²⁷, G L Ackland²⁸, L Gallego-Paredes²⁸, A Reyes²⁸, A Gutierrez Del Arroyo²⁸, A Raj²⁹, R Lifford²⁹, B H Cuthbertson, D N Wijeysundera, R M Pearse, P S Myles, T E F Abbott, M A Shulman, B H Cuthbertson, D N Wijeysundera, E Torres, A Ambosta, M Melo, M Mamdani, K E Thorpe, R M Pearse, T E F Abbott, P S Myles, M A Shulman, S Wallace, C Farrington, B L Croal, M P W Grocott, J T Granton, P Oh, B Thompson, D Levett, G Hillis, W S Beattie, H C Wijeysundera, B H Cuthbertson, D N Wijeysundera, R M Pearse, M A Shulman, T E F Abbott, E Torres, A Ambosta, B L Croal, J T Granton, K E Thorpe, M P W Grocott, C Farrington, S Wallace, P S Myles

Affiliations

¹ Department of Anesthesia, University of Toronto, Toronto, ON, Canada; Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada.
² Applied Health Research Centre, St. Michael's Hospital, Toronto, ON, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
³ Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada; Department of Medicine, St. Michael's Hospital, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada.
⁴ Department of Anesthesia, University of Toronto, Toronto, ON, Canada; Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada; Department of Anesthesia, St. Michael's Hospital, Toronto, ON, Canada. Electronic address: d.wijeysundera@utoronto.ca.
⁵ Alfred Hospital, Australia.
⁶ John Hunter Hospital, Australia.
⁷ Nambour General Hospital, Australia.
⁸ Peter McCallum Cancer Centre, Australia.
⁹ Prince Charles Hospital, Australia.
¹⁰ Princess Alexandra Hospital, Australia.
¹¹ Royal Adelaide Hospital, Australia.
¹² Royal Hobart Hospital, Australia.
¹³ Royal Melbourne Hospital, Australia.
¹⁴ Western Health, Australia.
¹⁵ St Michael's Hospital, Canada.
¹⁶ Sunnybrook Health Sciences Centre, Canada.
¹⁷ Toronto General Hospital, Canada.
¹⁸ Toronto Rehabilitation Institute - Rumsey Centre, Canada.
¹⁹ Toronto Western Hospital, Canada.
²⁰ Auckland City Hospital, New Zealand.
²¹ Middlemore Hospital, New Zealand.
²² Wellington Hospital, New Zealand.
²³ Aberdeen Royal Infirmary, United Kingdom.
²⁴ Royal Free Hospital, United Kingdom.
²⁵ Royal London Hospital, United Kingdom.
²⁶ Royal Marsden Hospital, United Kingdom.
²⁷ Southampton General Hospital, United Kingdom.
²⁸ University College London Hospital, United Kingdom.
²⁹ Whipps Cross Hospital, United Kingdom.

PMID: 31227271
PMCID: PMC6676367
DOI: 10.1016/j.bja.2019.04.058

Comment

Association of preoperative anaemia with cardiopulmonary exercise capacity and postoperative outcomes in noncardiac surgery: a substudy of the Measurement of Exercise Tolerance before Surgery (METS) Study

J Bartoszko et al. Br J Anaesth. 2019 Aug.

. 2019 Aug;123(2):161-169.

doi: 10.1016/j.bja.2019.04.058. Epub 2019 Jun 19.

Authors

Collaborators

P S Myles⁵, M A Shulman⁵, S Wallace⁵, C Farrington⁵, B Thompson⁵, M Ellis⁵, B Borg⁵, R K Kerridge⁶, J Douglas⁶, J Brannan⁶, J Pretto⁶, M G Godsall⁷, N Beauchamp⁷, S Allen⁷, A Kennedy⁷, E Wright⁷, J Malherbe⁷, H Ismail⁸, B Riedel⁸, A Melville⁸, H Sivakumar⁸, A Murmane⁸, K Kenchington⁸, Y Kirabiyik⁸, U Gurunathan⁹, C Stonell⁹, K Brunello⁹, K Steele⁹, O Tronstad⁹, P Masel⁹, A Dent⁹, E Smith⁹, A Bodger⁹, M Abolfathi⁹, P Sivalingam¹⁰, A Hall¹⁰, T W Painter¹¹, S Macklin¹¹, A Elliott¹¹, A M Carrera¹¹, N C S Terblanche¹², S Pitt¹², J Samuels¹², C Wilde¹², K Leslie¹³, A MacCormick¹³, D Bramley¹⁴, A M Southcott¹⁴, J Grant¹⁴, H Taylor¹⁴, S Bates¹⁴, M Towns¹⁴, A Tippett¹⁴, F Marshall¹⁴, C D Mazer¹⁵, J Kunasingam¹⁵, A Yagnik¹⁵, C Crescini¹⁵, S Yagnik¹⁵, C J L McCartney¹⁶, S Choi¹⁶, P Somascanthan¹⁶, K Flores¹⁶, D N Wijeysundera¹⁷, W S Beattie¹⁷, K Karkouti¹⁷, H A Clarke¹⁷, A Jerath¹⁷, S A McCluskey¹⁷, M Wasowicz¹⁷, J T Granton¹⁷, L Day¹⁷, J Pazmino-Canizares¹⁷, P Oh¹⁸, R Belliard¹⁸, L Lee¹⁸, K Dobson¹⁸, V Chan¹⁹, R Brull¹⁹, N Ami¹⁹, M Stanbrook¹⁹, K Hagen²⁰, D Campbell²⁰, T Short²⁰, J Van Der Westhuizen²⁰, K Higgie²⁰, H Lindsay²⁰, R Jang²⁰, C Wong²⁰, D Mcallister²⁰, M Ali²⁰, J Kumar²⁰, E Waymouth²⁰, C Kim²⁰, J Dimech²¹, M Lorimer²¹, J Tai²¹, R Miller²¹, R Sara²¹, A Collingwood²¹, S Olliff²¹, S Gabriel²¹, H Houston²¹, P Dalley²², S Hurford²², A Hunt²², L Andrews²², L Navarra²², A Jason-Smith²², H Thompson²², N McMillan²², G Back²², B L Croal²³, M Lum²³, D Martin²⁴, S James²⁴, H Filipe²⁴, M Pinto²⁴, S Kynaston²⁴, R M Pearse²⁵, T E F Abbott²⁵, M Phull²⁵, C Beilstein²⁵, P Bodger²⁵, K Everingham²⁵, Y Hu, E Niebrzegowska²⁵, C Corriea²⁵, T Creary²⁵, M Januszewska²⁵, T Ahmad²⁵, J Whalley²⁵, R Haslop²⁵, J McNeil²⁵, A Brown²⁵, N MacDonald²⁵, M Pakats²⁵, K Greaves²⁵, S Jhanji²⁶, R Raobaikady²⁶, E Black²⁶, M Rooms²⁶, H Lawrence²⁶, M Koutra²⁶, K Pirie²⁶, M Gertsman²⁶, S Jack²⁷, M Celinski²⁷, D Levett²⁷, M Edwards²⁷, K Salmon²⁷, C Bolger²⁷, L Loughney²⁷, L Seaward²⁷, H Collins²⁷, B Tyrell²⁷, N Tantony²⁷, K Golder²⁷, G L Ackland²⁸, L Gallego-Paredes²⁸, A Reyes²⁸, A Gutierrez Del Arroyo²⁸, A Raj²⁹, R Lifford²⁹, B H Cuthbertson, D N Wijeysundera, R M Pearse, P S Myles, T E F Abbott, M A Shulman, B H Cuthbertson, D N Wijeysundera, E Torres, A Ambosta, M Melo, M Mamdani, K E Thorpe, R M Pearse, T E F Abbott, P S Myles, M A Shulman, S Wallace, C Farrington, B L Croal, M P W Grocott, J T Granton, P Oh, B Thompson, D Levett, G Hillis, W S Beattie, H C Wijeysundera, B H Cuthbertson, D N Wijeysundera, R M Pearse, M A Shulman, T E F Abbott, E Torres, A Ambosta, B L Croal, J T Granton, K E Thorpe, M P W Grocott, C Farrington, S Wallace, P S Myles

Affiliations

¹ Department of Anesthesia, University of Toronto, Toronto, ON, Canada; Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada.
² Applied Health Research Centre, St. Michael's Hospital, Toronto, ON, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
³ Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada; Department of Medicine, St. Michael's Hospital, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada.
⁴ Department of Anesthesia, University of Toronto, Toronto, ON, Canada; Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada; Department of Anesthesia, St. Michael's Hospital, Toronto, ON, Canada. Electronic address: d.wijeysundera@utoronto.ca.
⁵ Alfred Hospital, Australia.
⁶ John Hunter Hospital, Australia.
⁷ Nambour General Hospital, Australia.
⁸ Peter McCallum Cancer Centre, Australia.
⁹ Prince Charles Hospital, Australia.
¹⁰ Princess Alexandra Hospital, Australia.
¹¹ Royal Adelaide Hospital, Australia.
¹² Royal Hobart Hospital, Australia.
¹³ Royal Melbourne Hospital, Australia.
¹⁴ Western Health, Australia.
¹⁵ St Michael's Hospital, Canada.
¹⁶ Sunnybrook Health Sciences Centre, Canada.
¹⁷ Toronto General Hospital, Canada.
¹⁸ Toronto Rehabilitation Institute - Rumsey Centre, Canada.
¹⁹ Toronto Western Hospital, Canada.
²⁰ Auckland City Hospital, New Zealand.
²¹ Middlemore Hospital, New Zealand.
²² Wellington Hospital, New Zealand.
²³ Aberdeen Royal Infirmary, United Kingdom.
²⁴ Royal Free Hospital, United Kingdom.
²⁵ Royal London Hospital, United Kingdom.
²⁶ Royal Marsden Hospital, United Kingdom.
²⁷ Southampton General Hospital, United Kingdom.
²⁸ University College London Hospital, United Kingdom.
²⁹ Whipps Cross Hospital, United Kingdom.

PMID: 31227271
PMCID: PMC6676367
DOI: 10.1016/j.bja.2019.04.058

Abstract

Background: Preoperative anaemia is associated with elevated risks of postoperative complications. This association may be explained by confounding related to poor cardiopulmonary fitness. We conducted a pre-specified substudy of the Measurement of Exercise Tolerance before Surgery (METS) study to examine the associations of preoperative haemoglobin concentration with preoperative cardiopulmonary exercise testing performance (peak oxygen consumption, anaerobic threshold) and postoperative complications.

Methods: The substudy included a nested cross-sectional analysis and nested cohort analysis. In the cross-sectional study (1279 participants), multivariate linear regression modelling was used to determine the adjusted association of haemoglobin concentration with peak oxygen consumption and anaerobic threshold. In the nested cohort study (1256 participants), multivariable logistic regression modelling was used to determine the adjusted association of haemoglobin concentration, peak oxygen consumption, and anaerobic threshold with the primary endpoint (composite outcome of death, cardiovascular complications, acute kidney injury, or surgical site infection) and secondary endpoint (moderate or severe complications).

Results: Haemoglobin concentration explained 3.8% of the variation in peak oxygen consumption and anaerobic threshold (P<0.001). Although not associated with the primary endpoint, haemoglobin concentration was associated with moderate or severe complications after adjustment for peak oxygen consumption (odds ratio=0.86 per 10 g L^-1 increase; 95% confidence interval, 0.77-0.96) or anaerobic threshold (odds ratio=0.86; 95% confidence interval, 0.77-0.97). Lower peak oxygen consumption was associated with moderate or severe complications without effect modification by haemoglobin concentration (P=0.12).

Conclusion: Haemoglobin concentration explains a small proportion of variation in exercise capacity. Both anaemia and poor functional capacity are associated with postoperative complications and may therefore be modifiable targets for preoperative optimisation.

Keywords: anaemia; cardiopulmonary exercise testing; exercise tolerance; perioperative period; postoperative complications.

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Figures

**Fig 1**
Participant recruitment, screening, and follow-up. CPET, cardiopulmonary exercise testing; METS, Measurement of Exercise Tolerance before Surgery.

**Fig 2**
Fit plots for unadjusted linear regression modelling of haemoglobin concentration with VO₂ peak and anaerobic threshold (AT). (a) Association between haemoglobin concentration and VO₂ peak. (b) Association between haemoglobin concentration and anaerobic threshold.

See this image and copyright information in PMC

Comment on

Association between preoperative haemoglobin concentration and cardiopulmonary exercise variables: a multicentre study.
Otto JM, O'Doherty AF, Hennis PJ, Cooper JA, Grocott MP, Snowdon C, Carlisle JB, Swart M, Richards T, Montgomery HE. Otto JM, et al. Perioper Med (Lond). 2013 Sep 13;2(1):18. doi: 10.1186/2047-0525-2-18. Perioper Med (Lond). 2013. PMID: 24472426 Free PMC article.
Total haemoglobin mass, but not haemoglobin concentration, is associated with preoperative cardiopulmonary exercise testing-derived oxygen-consumption variables.
Otto JM, Plumb JOM, Wakeham D, Clissold E, Loughney L, Schmidt W, Montgomery HE, Grocott MPW, Richards T. Otto JM, et al. Br J Anaesth. 2017 May 1;118(5):747-754. doi: 10.1093/bja/aew445. Br J Anaesth. 2017. PMID: 28510737

References

1. Clevenger B., Richards T. Pre-operative anaemia. Anaesthesia. 2015;70(20–8):e6–e8. - PubMed
1. Otto J.M., Montgomery H.E., Richards T. Haemoglobin concentration and mass as determinants of exercise performance and of surgical outcome. Extrem Physiol Med. 2013;2:33. - PMC - PubMed
1. Karkouti K., Wijeysundera D.N., Beattie W.S. Risk associated with preoperative anemia in cardiac surgery: a multicenter cohort study. Circulation. 2008;117:478–484. - PubMed
1. Hans G.A., Jones N. Preoperative anaemia. Contin Educ Anaesth Crit Care Pain. 2013;13:71–74.
1. Shander A., Javidroozi M., Ozawa S., Hare G.M. What is really dangerous: anaemia or transfusion? Br J Anaesth. 2011;107:i41–i59. - PubMed

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Association of preoperative anaemia with cardiopulmonary exercise capacity and postoperative outcomes in noncardiac surgery: a substudy of the Measurement of Exercise Tolerance before Surgery (METS) Study

Collaborators

Affiliations

Association of preoperative anaemia with cardiopulmonary exercise capacity and postoperative outcomes in noncardiac surgery: a substudy of the Measurement of Exercise Tolerance before Surgery (METS) Study

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Affiliations

Abstract

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