2025/06/04 by Kyosuke Takahashi, Tokujiro Uchida · 1 voice
Economics, Econometrics and Finance · Medicine · #Cardiac, Anesthesia and Surgical Outcomes #Frailty in Older Adults #Health Systems, Economic Evaluations, Quality of Life
paper · pdf · doi:10.1111/anae.16657
openalex publication_date 2025/06/04 · openalex created_date 2025/10/10 · openalex updated_date 2026/07/15
We thank Noppè et al. [1] for their insightful comments on our study [2]. They highlight the heterogeneity of included studies and the difficulty in converting subjective functional capacity into metabolic equivalents (METs). The utility of frailty assessment was also mentioned in the context of peri-operative risk stratification. We agree that heterogeneity observed in secondary outcomes should not be overlooked. Our systematic review included diverse evaluation methods of subjective functional capacity across varied non-cardiac surgical populations, and the observed heterogeneity may reflect this clinical and methodological diversity. Subgroup analysis could have provided further insight but was not feasible due to the limited number of studies included. Some evaluation methods were represented by only a single study. Nevertheless, all studies included in the secondary outcome analysis showed positive odds ratios, indicating a consistent direction of effect. Thus, while the magnitude of risk may vary, subjective functional capacity appears to be generally associated with adverse outcomes including cardiovascular events, mortality and other postoperative complications. The conversion between subjective and objective functional capacity is controversial. As noted, equating stair climbing to ≥ 4 METs is practiced commonly but not validated. Even validated instruments like the Duke Activity Status Index (DASI) only show moderate correlation with VO2 peak [3]. A recent study has also described that METs derived from DASI and cardiopulmonary exercise testing were significantly different [4]. Despite these limitations, classifying subjective functional capacity in terms of METs remains clinically meaningful, particularly for anaesthetists who use this framework routinely to estimate peri-operative risk. Importantly, subjective and objective functional capacity are not fully interchangeable as they assess overlapping but distinct constructs and may identify different at-risk populations. We also agree that frailty is an important and complementary predictor of peri-operative outcomes. Frailty captures broader physiologic vulnerability that may not be reflected by functional capacity alone. As emphasised in current European guidelines [5], frailty assessment should be incorporated, particularly in older patients. Frailty has been linked to not only postoperative complications, but also new functional disabilities and discharge to higher levels of care [6] – outcomes of critical relevance to patients' quality of life. These outcomes are beyond what functional capacity measures predict. Therefore, multidimensional assessment, including frailty alongside subjective and objective functional capacity, offers a more complete picture of surgical risk. Such comprehensive assessment could enhance the peri-operative risk stratification and patient care. Future studies are needed to clarify indications for each evaluation method and guide management of the risks they identify.