The usefulness of the modified steep ramp test as a practical exercise test for preoperative risk assessment in patients scheduled for pancreatic surgery

Heleen Driessens; Lis S.M. Hoeijmakers; Olav D.J. Zwerver; Allard G. Wijma; Nicole D. Hildebrand; Remy R.Y.C. Queisen; Mayella Kuikhoven; Marcel den Dulk; Steven W.M. Olde Damink; Joost M. Klaase; Bart C. Bongers

doi:10.1016/j.jclinane.2025.111916

The usefulness of the modified steep ramp test as a practical exercise test for preoperative risk assessment in patients scheduled for pancreatic surgery

Heleen Driessens
, Lis S.M. Hoeijmakers
, Olav D.J. Zwerver
, Allard G. Wijma
, Nicole D. Hildebrand
, Remy R.Y.C. Queisen
, Mayella Kuikhoven
, Marcel den Dulk
, Steven W.M. Olde Damink
, Joost M. Klaase
, Bart C. Bongers^*

^*Corresponding author for this work

Research output: Contribution to journal › Article › Academic › peer-review

Abstract

Background: The widespread implementation of a preoperative assessment of aerobic capacity requires a practical field test. This study investigated the validity of the modified steep ramp test (SRT) for evaluating preoperative aerobic capacity and to evaluate its usefulness for preoperative risk assessment in patients planned for pancreatic surgery. Methods: Patients scheduled for pancreatic surgery who preoperatively performed cardiopulmonary exercise testing (CPET) and the modified SRT within 14 days were included. To assess its criterion validity, the correlation between the achieved work rate at peak exercise (WR<inf>peak</inf>) at the modified SRT and oxygen uptake (VO<inf>2</inf>) at peak exercise (VO<inf>2peak</inf>) during CPET was determined. To evaluate the ability of the modified SRT to correctly classify patients as fit or unfit, receiver operating characteristic (ROC) analyses were performed based on the CPET VO<inf>2peak</inf> cutoff 18.0 ml.kg-1.min-1 and VO<inf>2</inf> at the ventilatory anaerobic threshold (VAT) cutoff 11.0 ml.kg-1.min-1. Results: Forty-eight patients (21 females) aged 68.7 ± 7.6 years were included. Modified SRT WR<inf>peak</inf> (W/kg) demonstrated a very strong correlation with CPET VO<inf>2peak</inf> (? = 0.865, r = 0.926). The modified SRT WR<inf>peak</inf> cutoff to most accurately classify patients as fit or unfit was 2.095 W/kg for the CPET VO<inf>2peak</inf> cutoff (area under the curve (AUC) of 0.948) and the CPET VO<inf>2</inf> at the VAT cutoff (AUC of 0.814). Conclusions: The modified SRT is a valid short-term practical exercise test to preoperatively assess aerobic capacity in patients undergoing pancreatic surgery. A modified SRT performance below 2.1 W/kg seems clinically most suitable to select candidates for further preoperative CPET evaluation and/or prehabilitation, given its positive and negative predictive value.

Original language	English
Article number	111916
Number of pages	8
Journal	Journal of Clinical Anesthesia
Volume	106
DOIs	https://doi.org/10.1016/j.jclinane.2025.111916
Publication status	Published - 1 Sept 2025

Keywords

Cardiorespiratory fitness
Functional capacity
Physical fitness
Prehabilitation
Preoperative care
Risk stratification

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Driessens, H., Hoeijmakers, L. S. M., Zwerver, O. D. J., Wijma, A. G., Hildebrand, N. D., Queisen, R. R. Y. C., Kuikhoven, M., den Dulk, M., Olde Damink, S. W. M., Klaase, J. M., & Bongers, B. C. (2025). The usefulness of the modified steep ramp test as a practical exercise test for preoperative risk assessment in patients scheduled for pancreatic surgery. Journal of Clinical Anesthesia, 106, Article 111916. https://doi.org/10.1016/j.jclinane.2025.111916

@article{9be15cf8f54f4b548c05e8e8b185fae2,

title = "The usefulness of the modified steep ramp test as a practical exercise test for preoperative risk assessment in patients scheduled for pancreatic surgery",

abstract = "Background: The widespread implementation of a preoperative assessment of aerobic capacity requires a practical field test. This study investigated the validity of the modified steep ramp test (SRT) for evaluating preoperative aerobic capacity and to evaluate its usefulness for preoperative risk assessment in patients planned for pancreatic surgery. Methods: Patients scheduled for pancreatic surgery who preoperatively performed cardiopulmonary exercise testing (CPET) and the modified SRT within 14 days were included. To assess its criterion validity, the correlation between the achieved work rate at peak exercise (WRpeak) at the modified SRT and oxygen uptake (VO2) at peak exercise (VO2peak) during CPET was determined. To evaluate the ability of the modified SRT to correctly classify patients as fit or unfit, receiver operating characteristic (ROC) analyses were performed based on the CPET VO2peak cutoff 18.0 ml.kg-1.min-1 and VO2 at the ventilatory anaerobic threshold (VAT) cutoff 11.0 ml.kg-1.min-1. Results: Forty-eight patients (21 females) aged 68.7 ± 7.6 years were included. Modified SRT WRpeak (W/kg) demonstrated a very strong correlation with CPET VO2peak (? = 0.865, r = 0.926). The modified SRT WRpeak cutoff to most accurately classify patients as fit or unfit was 2.095 W/kg for the CPET VO2peak cutoff (area under the curve (AUC) of 0.948) and the CPET VO2 at the VAT cutoff (AUC of 0.814). Conclusions: The modified SRT is a valid short-term practical exercise test to preoperatively assess aerobic capacity in patients undergoing pancreatic surgery. A modified SRT performance below 2.1 W/kg seems clinically most suitable to select candidates for further preoperative CPET evaluation and/or prehabilitation, given its positive and negative predictive value.",

keywords = "Cardiorespiratory fitness, Functional capacity, Physical fitness, Prehabilitation, Preoperative care, Risk stratification",

author = "Heleen Driessens and Hoeijmakers, \{Lis S.M.\} and Zwerver, \{Olav D.J.\} and Wijma, \{Allard G.\} and Hildebrand, \{Nicole D.\} and Queisen, \{Remy R.Y.C.\} and Mayella Kuikhoven and \{den Dulk\}, Marcel and \{Olde Damink\}, \{Steven W.M.\} and Klaase, \{Joost M.\} and Bongers, \{Bart C.\}",

note = "Publisher Copyright: {\textcopyright} 2025 The Authors",

year = "2025",

month = sep,

day = "1",

doi = "10.1016/j.jclinane.2025.111916",

language = "English",

volume = "106",

journal = "Journal of Clinical Anesthesia",

issn = "0952-8180",

publisher = "Elsevier Inc.",

}

Driessens, H, Hoeijmakers, LSM, Zwerver, ODJ, Wijma, AG, Hildebrand, ND, Queisen, RRYC, Kuikhoven, M, den Dulk, M , Olde Damink, SWM, Klaase, JM & Bongers, BC 2025, 'The usefulness of the modified steep ramp test as a practical exercise test for preoperative risk assessment in patients scheduled for pancreatic surgery', Journal of Clinical Anesthesia, vol. 106, 111916. https://doi.org/10.1016/j.jclinane.2025.111916

The usefulness of the modified steep ramp test as a practical exercise test for preoperative risk assessment in patients scheduled for pancreatic surgery. / Driessens, Heleen; Hoeijmakers, Lis S.M.; Zwerver, Olav D.J. et al.
In: Journal of Clinical Anesthesia, Vol. 106, 111916, 01.09.2025.

Research output: Contribution to journal › Article › Academic › peer-review

TY - JOUR

T1 - The usefulness of the modified steep ramp test as a practical exercise test for preoperative risk assessment in patients scheduled for pancreatic surgery

AU - Driessens, Heleen

AU - Hoeijmakers, Lis S.M.

AU - Zwerver, Olav D.J.

AU - Wijma, Allard G.

AU - Hildebrand, Nicole D.

AU - Queisen, Remy R.Y.C.

AU - Kuikhoven, Mayella

AU - den Dulk, Marcel

AU - Olde Damink, Steven W.M.

AU - Klaase, Joost M.

AU - Bongers, Bart C.

PY - 2025/9/1

Y1 - 2025/9/1

N2 - Background: The widespread implementation of a preoperative assessment of aerobic capacity requires a practical field test. This study investigated the validity of the modified steep ramp test (SRT) for evaluating preoperative aerobic capacity and to evaluate its usefulness for preoperative risk assessment in patients planned for pancreatic surgery. Methods: Patients scheduled for pancreatic surgery who preoperatively performed cardiopulmonary exercise testing (CPET) and the modified SRT within 14 days were included. To assess its criterion validity, the correlation between the achieved work rate at peak exercise (WRpeak) at the modified SRT and oxygen uptake (VO2) at peak exercise (VO2peak) during CPET was determined. To evaluate the ability of the modified SRT to correctly classify patients as fit or unfit, receiver operating characteristic (ROC) analyses were performed based on the CPET VO2peak cutoff 18.0 ml.kg-1.min-1 and VO2 at the ventilatory anaerobic threshold (VAT) cutoff 11.0 ml.kg-1.min-1. Results: Forty-eight patients (21 females) aged 68.7 ± 7.6 years were included. Modified SRT WRpeak (W/kg) demonstrated a very strong correlation with CPET VO2peak (? = 0.865, r = 0.926). The modified SRT WRpeak cutoff to most accurately classify patients as fit or unfit was 2.095 W/kg for the CPET VO2peak cutoff (area under the curve (AUC) of 0.948) and the CPET VO2 at the VAT cutoff (AUC of 0.814). Conclusions: The modified SRT is a valid short-term practical exercise test to preoperatively assess aerobic capacity in patients undergoing pancreatic surgery. A modified SRT performance below 2.1 W/kg seems clinically most suitable to select candidates for further preoperative CPET evaluation and/or prehabilitation, given its positive and negative predictive value.

AB - Background: The widespread implementation of a preoperative assessment of aerobic capacity requires a practical field test. This study investigated the validity of the modified steep ramp test (SRT) for evaluating preoperative aerobic capacity and to evaluate its usefulness for preoperative risk assessment in patients planned for pancreatic surgery. Methods: Patients scheduled for pancreatic surgery who preoperatively performed cardiopulmonary exercise testing (CPET) and the modified SRT within 14 days were included. To assess its criterion validity, the correlation between the achieved work rate at peak exercise (WRpeak) at the modified SRT and oxygen uptake (VO2) at peak exercise (VO2peak) during CPET was determined. To evaluate the ability of the modified SRT to correctly classify patients as fit or unfit, receiver operating characteristic (ROC) analyses were performed based on the CPET VO2peak cutoff 18.0 ml.kg-1.min-1 and VO2 at the ventilatory anaerobic threshold (VAT) cutoff 11.0 ml.kg-1.min-1. Results: Forty-eight patients (21 females) aged 68.7 ± 7.6 years were included. Modified SRT WRpeak (W/kg) demonstrated a very strong correlation with CPET VO2peak (? = 0.865, r = 0.926). The modified SRT WRpeak cutoff to most accurately classify patients as fit or unfit was 2.095 W/kg for the CPET VO2peak cutoff (area under the curve (AUC) of 0.948) and the CPET VO2 at the VAT cutoff (AUC of 0.814). Conclusions: The modified SRT is a valid short-term practical exercise test to preoperatively assess aerobic capacity in patients undergoing pancreatic surgery. A modified SRT performance below 2.1 W/kg seems clinically most suitable to select candidates for further preoperative CPET evaluation and/or prehabilitation, given its positive and negative predictive value.

KW - Cardiorespiratory fitness

KW - Functional capacity

KW - Physical fitness

KW - Prehabilitation

KW - Preoperative care

KW - Risk stratification

U2 - 10.1016/j.jclinane.2025.111916

DO - 10.1016/j.jclinane.2025.111916

M3 - Article

SN - 0952-8180

VL - 106

JO - Journal of Clinical Anesthesia

JF - Journal of Clinical Anesthesia

M1 - 111916

ER -

The usefulness of the modified steep ramp test as a practical exercise test for preoperative risk assessment in patients scheduled for pancreatic surgery

Abstract

Keywords

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