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Prognostic value of the Duke Activity Status Index for preoperative cardiac risk stratification: an international
Duminda N Wijeysundera1,2,3, Brian H Cuthbertson2,4, Emmanuelle Duceppe5
1Department of Anesthesia, St. Michael's Hospital - Unity Health Toronto, Toronto, Ontario, Canada.
Insights
The Duke Activity Status Index (DASI) offers additional prognostic value for preoperative cardiac risk assessment beyond standard predictors. However, its clinical impact is modest and best used as a continuous marker alongside other risk factors.
Area of Science:
- Cardiology
- Anesthesiology
- Geriatric Medicine
- Health Services Research
Background:
- Guidelines recommend functional capacity assessment for preoperative cardiac risk stratification, including the Duke Activity Status Index (DASI).
- Evidence for DASI's incremental prognostic value beyond established risk factors is limited.
- This study evaluated DASI's prognostic performance using pooled data from two prospective cohorts.
Purpose of the Study:
- To assess the incremental prognostic value of the Duke Activity Status Index (DASI) in preoperative cardiac risk stratification.
- To determine if DASI improves risk prediction beyond established factors like age, RCRI, and natriuretic peptides.
- To evaluate DASI's performance as a continuous marker versus a dichotomous screening tool.
Main Methods:
- Pooled cohort analysis of 3485 adults undergoing elective major non-cardiac surgery from METS and FIT After Surgery studies (March 2013-April 2023).
- Preoperative assessment included DASI questionnaire and biomarker measurement.
- Hierarchical logistic regression analyzed DASI's incremental value for 30-day major adverse cardiac events or death, and all-cause major complications.
Main Results:
- DASI provided incremental prognostic information for the primary outcome (cardiac complications/death) and secondary outcome (all-cause complications).
- Inclusion of DASI improved prognostic performance metrics, but overall model discrimination remained modest (c-index 0.70-0.71).
- Predicted risk varied significantly by DASI score, age, RCRI, and natriuretic peptide concentration, supporting its use as a continuous marker.
Conclusions:
- The Duke Activity Status Index (DASI) offers incremental prognostic information for preoperative cardiac risk assessment beyond guideline-recommended predictors.
- DASI's prognostic implications are modest and context-dependent.
- DASI is best interpreted as a continuous prognostic marker alongside established risk factors, not a stand-alone threshold-based tool.
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.
