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Editorials |

The 6-Min Walk Distance in Pulmonary Arterial Hypertension: “Je t’aime, moi non plus”

Robert Naeije, MD, PhD
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From the Department of Physiology, Faculty of Medicine of the Free University of Brussels

Correspondence to: Robert Naeije, MD, PhD, Department of Physiology, Faculty of Medicine of the Free University of Brussels, CP 604, Lennik Rd 808, B-1070 Brussels, Belgium; e-mail: rnaeije@ulb.ac.be


Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestpubs.org/site/misc/reprints.xhtml).


© 2010 American College of Chest Physicians


Chest. 2010;137(6):1258-1260. doi:10.1378/chest.10-0351
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Exercise capacity measured by the distance walked in 6 min (6MWD) has been successfully used as a primary endpoint in most of the randomized controlled trials that have led to the registration of efficacious pharmacologic therapies for pulmonary arterial hypertension (PAH) during the last 2 decades.1 As for any biomarker of disease severity, relationships are indirect and, therefore, not necessarily tight. However, a metaanalysis has confirmed that patients with PAH who improve their 6MWD after only a few weeks of any treatment also present with consistent improvements in functional state, hemodynamics, and survival.2 Accordingly, the 6MWD is integrated in clinical decision making, goal-oriented treatment strategies, and newly designed event-driven trials for the diagnosis of clinical deterioration.3 The measurement of a 6MWD is simple, safe, of negligible cost, applicable to daily activities, correlated to peak oxygen uptake (V. o2), and highly reproducible after a modest < 10% improvement on repeated initial testing.4 It has been shown that patients performing the walk test quickly stabilize at a metabolic rate equivalent to the highest achievable V. o2 with a respiratory exchange ratio equal to or just less than one, which makes the 6MWD a particularly robust measure of purely aerobic exercise capacity.5 It is, therefore, intriguing that many experts persistently sweep negative statements against the use of the 6MWD in the evaluation of PAH, with a variety of arguments ranging from lack of scientific rationale to multifactorial determination of the results.6,7 The belief that the 6MWD is flawed in PAH has triggered expert consensus conferences aimed at the determination of improved trial designs, which actually resulted in the integration of the measurement into more composite end points.8 There seems to be a hate-love relationship between the 6MWD and the PAH community, much alike the “Je t’aime, moi non plus” song that used to be popularized by Serge Gainsbourg and Brigitte Bardot. This should not be further exacerbated by the report of Degano and colleagues,9 also from France, published in this issue of CHEST (see page 1297).

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