TITLE: The Six Minute Walk Test: Clinical Effectiveness and Guidelines

DATE: 15 April 2010

RESEARCH QUESTIONS:

1. What is the clinical effectiveness of the six minute walk test in patients with chronic heart
failure?

2. What are the guidelines regarding use of the six minute walk test in patients with chronic
heart failure?

METHODS:

A limited literature search was conducted on key health technology assessment resources,
including PubMed, the Cochrane Library (Issue 3, 2010), University of York Centre for Reviews
and Dissemination (CRD) databases, ECRI (Health Devices Gold), EuroScan, international
health technology agencies, and a focused Internet search. The search was limited to English
language articles published between 2005 and March 31, 2010. Filters were applied to limit the
retrieval to health technology assessments, systematic reviews, meta-analyses, randomized
controlled trials, controlled clinical trials, observational studies, and guidelines. Internet links
were provided, where available.

The summary of findings was prepared from the abstracts of the relevant information. Please
note that data contained in abstracts may not always be an accurate reflection of the data
contained within the full article.

RESULTS:

HTIS reports are organized so that the higher quality evidence is presented first. Therefore,
health technology assessment reports, systematic reviews, and meta-analyses are presented
first. These are followed by randomized controlled trials, controlled clinical trials, observational
studies, and evidence-based guidelines.

Disclaimer: The Health Technology Inquiry Service (HTIS) is an information service for those involved in planning and providing
health care in Canada. HTIS responses are based on a limited literature search and are not comprehensive, systematic reviews.
The intent is to provide a list of sources of the best evidence on the topic that CADTH could identify using all reasonable efforts
within the time allowed. HTIS responses should be considered along with other types of information and health care considerations.
The information included in this response is not intended to replace professional medical advice, nor should it be construed as a
recommendation for or against the use of a particular health technology. Readers are also cautioned that a lack of good quality
evidence does not necessarily mean a lack of effectiveness particularly in the case of new and emerging health technologies, for
which little information can be found, but which may in future prove to be effective. While CADTH has taken care in the preparation
of the report to ensure that its contents are accurate, complete and up to date, CADTH does not make any guarantee to that effect.
CADTH is not liable for any loss or damages resulting from use of the information in the report.

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Two systematic reviews, 19 observational studies, and one evidence-based guideline were
identified pertaining to the use of the six minute walk test (6MWT) in patients with chronic heart
failure (CHF). No relevant health technology assessment reports, randomized controlled trials,
or controlled clinical trials were identified. Additional information that may be of interest has
been included in the appendix.

OVERALL SUMMARY OF FINDINGS:

The identified studies assessed the use of the 6MWT in patients with CHF of varying severity
and in various clinical settings. Overall, the evidence suggests that the 6MWT seems to be a
useful and clinically effective tool in order to determine prognosis,3,18,22 functional
capacity,1,5,715,17 cardiovascular morbidity and mortality,4,7,14,16 and potential exercise limitations.8
It is a tool that correlates well with global left ventricular systolic function parameters,5,15 one that
may be useful in the assessment of cardiac resynchronization therapy,2 and can be used when
ergospirometry is not available to determine maximal oxygen consumption.3 The 6MWT may not
be effective in determining risk for rehospitalization in hospitalized patients with heart failure
who are tested 24 hours prior to discharge,13 may not be an appropriate test for the assessment
of effective patient outcomes in randomized controlled trials for pharmacological interventions,2
and may not be useful as a repeated measure of clinical status in severe heart failure.19 While
some evidence suggest that the number of meters travelled in the 6MWT may not be an
indicator of CHF in all patients and that it may be necessary to standardize according to body
mass index (BMI), age, and gender,10 other studies have found that the prognostic power of the
6MWT was not increased by either adjusting for age, height, weight, or BMI alone in either
gender12 or by using published reference equations.11 The change in the distance walked in the
6MWT was found to be sensitive to self-perceived symptoms of heart failure.20 The identified
guideline recommends using the 6MWT to assess exercise limitations and prognosis in patients
with CHF.21

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REFERENCES SUMMARIZED:

Health technology assessments

No literature identified.

Systematic reviews and meta-analyses

1. Pollentier B, Irons SL, Benedetto CM, DiBenedetto A-M, Loton D, Seyler RD, et al.
Examination of the six minute walk test to determine functional capacity in people with
chronic heart failure: a systematic review. Cardiopulm Phys Ther J [Internet]. 2010 [cited
2010 Mar 31];21(1). Available from:
http://www.cardiopt.org/cppt/members/fulltext/2010/march/Examination%20of%20the%20
Six%20Minute%20Walk%20Test.pdf

2. Olsson LG, Swedberg K, Clark AL, Witte KK, Cleland JG. Six minute corridor walk test as
an outcome measure for the assessment of treatment in randomized, blinded intervention
trials of chronic heart failure: a systematic review. Eur Heart J [Internet]. 2005 Apr [cited
2010 Mar 31];26(8):778-93. PubMed: PM15774495 Available from:
http://eurheartj.oxfordjournals.org/content/26/8/778.full.pdf+html

Randomized controlled trials

No literature identified.

Controlled clinical trials

No literature identified.

Observational studies

3. Accuracy of six minute walk test, stair test and spirometry using maximal oxygen uptake
as gold standard. Acta Cirurgica Brasileira [Internet]. 2010 [cited 2010 Mar 31];25(2).
Available from: http://www.scielo.br/pdf/acb/v25n2/a13v25n2.pdf

4. Alahdab MT, Mansour IN, Napan S, Stamos TD. Six minute walk test predicts long-term
all-cause mortality and heart failure rehospitalization in African-American patients
hospitalized with acute decompensated heart failure. J Card Fail. 2009 Mar;15(2):130-5.
PubMed: PM19254672

5. Berisha V, Bajraktari G, Dobra D, Haliti E, Bajrami R, Elezi S. Echocardiography and 6-

minute walk test in left ventricular systolic dysfunction. Arq Bras Cardiol [Internet]. 2009
Feb [cited 2010 Mar 31] ;92(2):121-34. PubMed: PM19360245 Available from:
http://www.scielo.br/pdf/abc/v92n2/en_a09v92n2.pdf

6. Braunschweig F, Linde C, Adamson PB, Magalski A, Erdmann E, Kjellstrom B, et al.

Continuous central haemodynamic measurements during the six-minute walk test and
daily life in patients with chronic heart failure. Eur J Heart Fail. 2009 Jun;11(6):594-601.
PubMed: PM19468021

The Six Minute Walk Test 3

7. Castel MA, Méndez F, Tamborero D, Mont L, Magnani S, Tolosana JM, et al. Six-minute
walking test predicts long-term cardiac death in patients who received cardiac
resynchronization therapy. Europace [Internet]. 2009 Mar [cited 2010 Mar 31];11(3):338-
42. PubMed: PM19136491 Available from:
http://europace.oxfordjournals.org/content/11/3/338.full.pdf+html

8. Guazzi M, Dickstein K, Vicenzi M, Arena R. Six-minute walk test and cardiopulmonary

exercise testing in patients with chronic heart failure: a comparative analysis on clinical
and prognostic insights. Circ Heart Fail. 2009 Nov;2(6):549-55. PubMed: PM19919979

9. Jehn M, Halle M, Schuster T, Hanssen H, Weis M, Koehler F, et al. The 6-min walk test in
heart failure: is it a max or sub-maximum exercise test? Eur J Appl Physiol. 2009
Oct;107(3):317-23. PubMed: PM19618202

10. Balashov K, Feldman DE, Savard S, Houde S, Frenette M, Ducharme A, et al. Percent
predicted value for the 6-minute walk test: using norm-referenced equations to
characterize severity in persons with CHF. J Card Fail. 2008 Feb;14(1):75-81. PubMed:
PM18226776

11. Frankenstein L, Zugck C, Nelles M, Schellberg D, Katus H, Remppis A. Sex-specific

predictive power of 6-minute walk test in chronic heart failure is not enhanced using
percent achieved of published reference equations. J Heart Lung Transplant. 2008
Apr;27(4):427-34. PubMed: PM18374880

12. Frankenstein L, Remppis A, Graham J, Schellberg D, Sigg C, Nelles M, et al. Gender and
age related predictive value of walk test in heart failure: do anthropometrics matter in
clinical practice? Int J Cardiol. 2008 Jul 21;127(3):331-6. PubMed: PM17689763

13. Howie-Esquivel J, Dracup K. Does oxygen saturation or distance walked predict

rehospitalization in heart failure? J Cardiovasc Nurs. 2008 Jul;23(4):349-56. PubMed:
PM18596499

14. Arslan S, Erol MK, Gundogdu F, Sevimli S, Aksakal E, Senocak H, et al. Prognostic value
of 6-minute walk test in stable outpatients with heart failure. Tex Heart Inst J [Internet].
2007 [cited 2010 Mar 31];34(2):166-9. PubMed: PM17622362 Available from:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1894714/pdf/20070600s00006p166.pdf

15. Ingle L, Rigby AS, Carroll S, Butterly R, King RF, Cooke CB, et al. Prognostic value of the
6 min walk test and self-perceived symptom severity in older patients with chronic heart
failure. Eur Heart J [Internet]. 2007 Mar [cited 2010 Mar 31];28(5):560-8. PubMed:
PM17314108 Available from:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1894714/pdf/20070600s00006p166.pdf

16. Lee R, Chan YH, Wong J, Lau D, Ng K. The 6-minute walk test predicts clinical outcome
in Asian patients with chronic congestive heart failure on contemporary medical therapy: a
study of the multiracial population in Singapore. Int J Cardiol. 2007 Jul 10;119(2):168-75.
PubMed: PM17056135

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17. Hogenhuis J, Jaarsma T, Voors AA, Hillege HL, Lesman I, van Veldhuisen DJ. Correlates
of B-type natriuretic peptide and 6-min walk in heart failure patients. Int J Cardiol. 2006
Mar 22;108(1):63-7. PubMed: PM16516699

18. Passantino A, Lagioia R, Mastropasqua F, Scrutinio D. Short-term change in distance

walked in 6 min is an indicator of outcome in patients with chronic heart failure in clinical
practice. J Am Coll Cardiol. 2006 Jul 4;48(1):99-105. PubMed: PM16814655

19. Cheetham C, Taylor R, Burke V, O'Driscoll G, Green DJ. The 6-minute walk test does not
reliably detect changes in functional capacity of patients awaiting cardiac transplantation.
J Heart Lung Transplant. 2005 Jul;24(7):848-53. PubMed: PM15982612

20. Ingle L, Shelton RJ, Rigby AS, Nabb S, Clark AL, Cleland JG. The reproducibility and
sensitivity of the 6-min walk test in elderly patients with chronic heart failure. Eur Heart J
[Internet]. 2005 Sep [cited 2010 Mar 31];26(17):1742-51. PubMed: PM15831556 Available
from: http://eurheartj.oxfordjournals.org/content/26/17/1742.full.pdf+html

Guidelines and recommendations

21. JMO Arnold, P Liu, C Demers, et al. Canadian Cardiovascular Society consensus
conference recommendations on heart failure 2006: Diagnosis and management. Can J
Cardiol [Internet]. 2006 [cited 2010 Mar 31];22(1):23-45. Available from:
http://www.ccs.ca/download/consensus_conference/consensus_conference_archives/Arn
old_CCS_final.pdf
See page 25

PREPARED BY:
Health Technology Inquiry Service
Email: htis@cadth.ca
Tel: 1-866-898-8439

The Six Minute Walk Test 5

APPENDIX – FURTHER INFORMATION:

Clinical practice guidelines

22. In depth review of the six-minute walk test. In: StrokEngine-Assess [Internet]. Montreal:
McGill University; 2010. [cited 2010 Mar 31] Available from:
http://www.medicine.mcgill.ca/Strokengine-assess/module_6mwt_indepth-en.html

23. Task Force of the Italian Working Group on Cardiac Rehabilitation and Prevention, Piepoli
MF, Corrà U, Agostoni PG, Belardinelli R, Cohen-Solal A, et al. Statement on
cardiopulmonary exercise testing in chronic heart failure due to left ventricular dysfunction.
Recommendations for performance and interpretation. Eur J Cardiovasc Prev Rehabil.
2006 Feb;13(1):10-2. PubMed: PM16449859

Observational studies

24. Guimarães GV, Carvalho VO, Bocchi EA. Reproducibility of the self-controlled six-minute
walking test in heart failure patients. Clinics (Sao Paulo) [Internet]. 2008 Apr [cited 2010
Mar 31];63(2):201-6. PubMed: PM18438574 Available from:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2664221/pdf/cln63_2p0201.pdf

Review articles

25. Du H, Newton PJ, Salamonson Y, Carrieri-Kohlman VL, Davidson PM. A review of the six-
minute walk test: its implication as a self-administered assessment tool. Eur J Cardiovasc
Nurs. 2009 Mar;8(1):2-8. PubMed: PM18694656

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