EP-C

ACSM Preparticipation Screening Algorithm

(pp. 33-34) Note: A competent EP-C may oversee judicious use of preparticipation PA screening and graded exercise test for exercise prescription purposes in lower-risk clients.

Classification of COPD severity and severity of any spirometric abnormality

- (p. 60) - Spirometric classification of lung disease is useful in predicting health status, use of health resources, and mortality. Abnormal spirometry can be indicative of an increased risk for lung cancer, heart attack, and stroke, and can be used to identify patients in whom interventions such as smoking cessation and pharmacologic agents would be most beneficial. Also beneficial in identifying patients with chronic disease (COPD and heart failure, for examples) who have diminished pulmonary function and may benefit from an inspiratory muscle training program. - The maximal voluntary ventilation (MVV) should also be obtained during routine spirometric testing as it can be used to estimate breathing reserve during maximal exercise.

Absolute Contraindications

- Acute MI within 2 d - Ongoing unstable angina - Uncontrolled cardiac arrhythmia with hemodynamic compromise - Active endocarditis - Symptomatic severe aortic stenosis - Decompensated heart failure - Acute pulmonary embolism, pulmonary infarction, or deep venous thrombosis - Acute myocarditis or pericarditis - Acute aortic dissection - Physical disability that precludes safe and adequate testing

Physical Examination

- Appropriate components of physical examination specific to subsequent exercise testing - (p. 51) - Body weight/BMI/waist girth/body composition - Apical pulse rate and rhythm Resting BP - seated, supine, and standing - Auscultation of lungs with specific attention to uniformity of breath sounds in all areas (absence of rales, wheezes, and other breathing sounds) - Palpation of cardiac apical impulse and point of maximal impulse - Auscultation of heart with attention to murmurs, gallops, clicks, and rubs - Palpation/auscultation of carotid/abdominal/femoral arteries - Evaluation of abdomen for bowel sounds, masses, visceromegaly, and tenderness - Palpitation/inspection of LE for edema/presence of arterial pulses - Absence/presence of tendon xanthoma and skin xanthelasma - Follow-up exam related to orthopedic/medical conditions that would limit exercise testing - Tests of neurologic function including reflexes and cognition (as indicated) - Inspection of skin, especially of LE in diabetic patients

1. Pain/discomfort in chest, neck, jaw, arms, or other areas that may be due to ischemia or lack of oxygenated blood flow to the tissue, such as the heart, one of the cardinal manifestations of cardiac disease, in particular, CAD

- Character: constricting, squeezing, burning, "heaviness," "heavy feeling" - Location: substernal, across the midthorax, anteriorly, in one or both arms/shoulders, in neck, cheeks, or teeth, in forearms, fingers, and/or interscapular region - Provoking factors: comes with exercise/exertion, excitement, forms of stress, cold weather, after meals Key features against an ischemic origin: - Character: dull ache, "knifelike," sharp, stabbing, "jabs" aggravated by respiration - Location: in left submammary area, in left hemithorax - Provoking factors: after completion of exercise, provoked by a specific body motion

A 50YO nonsmoking male was recently invited by colleagues to participate in a 10km trail run. He reports currently walking 40 min on Monday, Wednesday, and Friday - something he has done "for years." His goal is to run the entire race without stopping, and he is seeking training services. He reports having what he describes as a "mild heart attack" at 45YO, completed cardiac rehab, and has had no problems since. He takes a statin, an angiotensin-converting enzyme (ACE) inhibitor, and aspirin daily. During the last visit with his cardiologist, which took place 2 yr ago, the cardiologist noted no changes in his medical condition.

- Currently participates in regular exercise? YES - Known CV, metabolic, or renal disease? YES - SS suggestive of disease? NO - Desired intensity? Vigorous - Medical clearance needed? YES

Recommended Laboratory Tests

All individuals: - Fasting serum total cholesterol, LDL cholesterol, HDL cholesterol, triglycerides - Fasting plasma glucose: for all, particularly those who are overweight/obese, testing should begin at age 45. Testing should be considered in all adults who are overweight/obese and have 1+ additional risk factor(s) for type II diabetes. Individuals with SS or known CVD: - Preceding tests plus pertinent previous cardiovascular laboratory tests as indicated (resting 12-lead EKG, Holter EKG monitoring, coronary angiography, radionuclide/echocardiography studies, previous exercise tests) - Carotid ultrasound and other peripheral vascular studies as indicated - Chest radiograph, if heart failure is present/suspected - Comprehensive blood chemistry panel and complete blood count as indicated by history/physical examination Patients with Pulmonary Disease: - Chest radiograph - Pulmonary function tests - Carbon monoxide diffusing capacity - Other specialized pulmonary studies (oximetry, blood gas analysis) - (p. 52)

5. Ankle edema/swelling

Ankle edema/swelling not due to injury is suggestive or heart failure, a blood clot, insufficiency of the veins, or a lymph system blockage. Generalized edema (anasarca) occurs in individuals with nephrotic syndrome, severe heart failure, or hepatic cirrhosis.

5. Obesity

BMI greater than or equal to 30 kg/m2 or waist circumference of greater than 102 cm for men and 88 cm for women. Body fat percentages, if available, may also be used.

1. Age

Client's age of 45+ YO for males and 55+ YO for females

3. Smoking

Current cigarette smoker, quit smoking within the last 6 months, or exposed to secondhand smoke on a regular basis

A 22YO recent college graduate is joining a gym. Since becoming an accountant 6 months ago, she no longer walks across campus or plays intramural soccer and has concerns about her now sedentary lifestyle. Although her BMI is slightly above normal, she reports no significant medical history and no symptoms of any diseases, even when walking up three flights of stairs to her apartment. She would like to begin playing golf.

Currently participates in regular exercise? NO - Known CV, metabolic, or renal disease? NO - SS suggestive of disease? NO - Desired intensity? Moderate - Medical clearance needed? NO

A 60 YO woman is beginning a professionally led walking program. Two years ago, she had a drug-eluting stent placed in her left anterior descending coronary artery after a routine exercise stress test revealed significant ST-segment depression. She completed a brief cardiac rehabilitation program in the 2 months following the procedure and has been inactive since. She reports no SS and takes a cholesterol-lowering statin and antiplatelet medications as directed by her cardiologist.

Currently participates in regular exercise? NO - Known CV, metabolic, or renal disease? YES - SS suggestive of disease? NO - Desired intensity? Moderate - Medical clearance needed? YES

A 35YO business consultant is in town for 2 weeks and seeking a temporary membership at a fitness club. She and her friends have been training for a long-distance charity bike ride the past 16 weeks; she is unable to travel with her bike and doesn't want to lose her fitness. She reports no symptoms of CV or metabolic disease and has no medical history except hyperlipidemia, for which she takes a HMG-CoA reductase inhibitor (statin) daily.

Currently participates in regular exercise? YES - Known CV, metabolic, or renal disease? NO - SS suggestive of disease? NO - Desired intensity? Vigorous - Medical clearance needed? NO

A 45YO former collegiate swimmer turned lifelong triathlete requests assistance with run training. His only significant medical history is a series of overuse injuries to his shoulder and Achilles tendon. In recent weeks, he notes his workouts are unusually difficult and reports feeling constriction in his chest with exertion - something he attributes to deficiencies in core strength. Upon further questioning, he explains that the chest constriction is improved with rest and that he often feels dizzy during recovery.

Currently participates in regular exercise? YES - Known CV, metabolic, or renal disease? NO - SS suggestive of disease? YES - Desired intensity? Vigorous - Medical clearance needed? YES

2. Family History

Family history of specific cardiovascular events (MI, coronary revascularization - bypass surgery/angioplasty, SCD), parents, siblings, children, at least one male relative has had such an event prior to age 55 or prior to age 65 in female relative

9. HDL-C

High-serum HDL-C equal or greater than 60 mg/dL is a negative risk factor, measured on at least two separate occasions.

3) assessment of presence of signs/symptoms suggestive of CMR disease (cardiac, peripheral vascular, cerebrovascular, types I and II diabetes, and renal diseases)

If a client has any of these SS, they are at a higher risk and medical clearance is recommended prior to participation in a PA program/8 SS suggestive of CMR: 1. Pain/discomfort in chest, neck, jaw, arms, or other areas that may be due to ischemia or lack of oxygenated blood flow to the tissue, such as the heart, one of the cardinal manifestations of cardiac disease, in particular, CAD 2. Dyspna 3. Snycope/fainting and dizziness 4. Orthopnea/Paroxysmal nocturnal dyspnea 5. Ankle edema/swelling 6. Palpitations/tachycardia 7. Intermittent claudication 8. Heart Murmers - Unusual fatigue/shortness of breath that occurs during light exertion/normal activity - may signal onset of or change in status of cardiovascular and/or metabolic disease.

Blood Pressure

- Decisions should be based on average of 2+ properly measured, seated BP readings Procedure: - Patient should be seated quietly in a chair for at least 5 min with back support with their feet on the floor and their arms supported at heart level. Patients should refrain from smoking or ingesting caffeine for at least 30 min preceding. - Measuring supine and standing values may be indicated under special circumstances. - Wrap cuff firmly around upper arm at heart level; align cuff with brachial artery. - Appropriate cuff size must be used; bladder within cuff should encircle at least 80% of upper arm. - Place stethoscope chest piece below antecubital space over brachial artery. - Quickly inflate cuff pressure to 20 mmHg above first Korotkoff sound. - Slowly release pressure at rate equal to 2-3 mmHg/s. SBP is point at which the first of 2+ Korotkoff sounds is heard (phase 1), and DBP is point before disappearance of Korotkoff sounds (phase 5). - At least 2 measurements should be made a minimum of 1 min apart, and the average should be taken. - BP should be measured in both arms during the first examination. Higher pressure should be used when there is a consistent interarm difference. - Provide to patients, verbally and in writing, their specific BP numbers and BP goals.

Classification and management of BP for Adults

Normal : - <120 & <80 - Lifestyle modification encouraged Prehypertension: - 120-139 or 80-89 - Yes lifestyle modification - No antihypertensive drugs indicated w/o compelling indication - Drugs for compelling indications (heart failure, known CAD, diabetes, etc.) Stage 1 Hypertension: - 140-159 or 90-99 - Yes lifestyle modification - Antihypertensive drugs indicated w/o compelling indication - With compelling indications, drugs for compelling indications and other antihypertensive drugs as needed. Stage 2 Hypertension: - greater or equal to 160 or greater or equal to 100 - Yes lifestyle modification - Without compelling indication, antihypertensive drugs indicated, two-drug combination for most - For 40-70 YO individuals, each increment of 20 mmHg in SBP or 10 mmHg in DBP doubles the risk of CVD across the entire BP range of 115/75 to 185/115 - Recommended BP goal for most patients is <140/90

4. Orthopnea/Paroxysmal Nocturnal Dyspnea

Orthopnea refers to trouble breathing while lying down. Paroxysmal nocturnal dyspnea refers to difficulty breathing while asleep, beginning usually 2-5 hours after onset of sleep, which may be relieved by sitting on the side of the bed or by getting out of bed. Both indicative of poor LV function.

Informed Consent

- Enough information must be present in the process to ensure that the participant knows/understands the purposes/risks associated with the test/exercise program in health/fitness or clinical settings. - Form should be verbally explained and include a statement indicating the client has been given an opportunity to ask questions and has sufficient information to give informed consent. Note specific questions asked and responses provided. - Must indicate the participant is free to withdraw - If a minor, legal guardian must sign - Advisable to check with authoritative bodies to determine what is appropriate for an acceptable informed consent process. - (p. 46) - All reasonable efforts must be made to protect the privacy of the patient's health information as described in the Health Insurance Portability and Accountability Act (HIPPA). - When test is for research purposes, this should be indicated during consent process. - Most consent forms include statement "emergency procedures and equipment are available" - available personnel are appropriately trained to carry out emergency procedures - sample - (p. 46)

A HHQ must minimally assess...

- Family history of CMR disease - Personal history of various diseases/illnesses including CMR disease - Surgical history - Past/present health behaviors/habits (such as history of cigarette smoking and PA) - Current use of various drugs/medications - Specific history of various signs/symptoms suggestive of CMR disease among other things - pp. 30-32

2) evaluated for presence of known CMR disease

- Heart attack - Heart surgery, cardiac catheterization, coronary angioplasty - pacemaker/implantable cardiac defibrillator/rhythm disturbance - Heart valve disease - Heart failure - Heart transplantation - Congenital heart disease - Type I or II diabetes - Renal disease such as renal failure

Screening is important to...

- Identify those with medical contraindications (exclusion criteria) for performing PA until those conditions are abated or better controlled - Identify those who should receive a medical/physical evaluation/exam / clearance prior to initiating a PA program or increasing the frequency, intensity, and/or volume of their current program - Identify those who should participate in a medically supervised PA program (with clinically significant diseases) - Identify those with other health/medical concerns (i.e., orthopedic injuries, etc.)

Preexercise Evaluation

- Informed consent procedure, medical history and CVD risk factor assessment, physical examination and laboratory tests, and participant instructions relate to both health/fitness and clinical exercise settings. - A comprehensive preexercise evaluation in the clinical setting generally includes a medical history and risk factor assessment, physical examination, and laboratory tests.

Relative Contraindications

- Known obstructive left main coronary artery stenosis - Moderate-severe aortic stenosis with uncertain relationship to symptoms - Tachyarrhythmias with uncontrolled ventricular rates - Acquired advanced or complete heart block - Recent stroke or transient ischemia attack - Mental impairment with limited ability to cooperate - Resting HT with systolic >200 mmHg or diastolic > 110 mmHg - Uncorrected medical conditions, such as significant anemia, important electrolyte imbalance, and hyperthyroidism

6. Palpitations/Tachycardia

Palpitations and tachycardia both refer to rapid beating/fluttering of the heart from tachycardia, bradycardia of sudden onset, ectopic beats, compensatory pauses, and accentuated stroke volume resulting from valvular regurgitation. Palpitations also result from anxiety states and high Q (or hyperkinetic) states, such as anemia, fever, thyrotoxicosis, arteriovenous fistula, and idiopathic hyperkinetic heart syndrome.

Lipids and Lipoproteins

- LCL-C identified as primary target for cholesterol-lowering therapy, as it is a powerful risk factor for CVD - Evidence of association between elevated triglycerides and CVD risk, although adjustment for other risk factors, especially HDL-C, appears to attenuate the relationship. - Intensity of therapy should be adjusted to individual's absolute risk for CVD. Therapeutic lifestyle changes are the cornerstone of therapy, with pharmacological therapy to lower LDL-C being used to achieve treatment goals when indicated. - Moderate-intensity or high-intensity statin therapy, which typically reduce LDL-C levels by 30-<50% and greater than or equal to 50% respectively, should be used as initial lipid-lowering therapy based on risk level and treatment goals (ACC/AHA). - LDL-C - < 100 mg/dL (optimal) - Total Cholesterol (<200 desirable) - HDL-C - <40 (low), >60 (high) - Triglycerides - <150 (normal) - Specific breakdown (low, optimal, borderline high, etc.) - (p. 56)

Medical Examination/Clearance

- Led by physician/qualified healthcare professional may also be necessary/desirable to help evaluate the health/medical status of client prior to PA program - In addition, may be desirable to perform some routine laboratory assessments (fasting blood cholesterol and/or resting BP) prior to PA programming - Note: The manner of clearance should be determined by the clinical judgement and the discretion of the healthcare provider - may include verbal consultations, resting or stress electrocardiogram/echocardiogram, computed tomography for the assessment of coronary artery calcium or nuclear medicine imaging studies or angiography.

1) past PA history/current level of PA

- Lower risk - 30+ min of at least mod PA on at least 3 d/wk for at least the last 3 months

Medical History

- Medical history should be thorough and include past/current information - Components of medical history - (p. 47) - Medical diagnoses and history of medical procedures: CVD risk factors (HT, obesity, dyslipidemia, diabetes), CVD (heart failure, valvular dysfunction, MI, other acute coronary syndromes), percutaneous coronary interventions (angioplasty, coronary stents, CABG, other cardiac surgeries - valvular surgeries, transplant, pacemaker/ICD, ablation procedures for dysrhythmias, peripheral valvular disease), pulmonary disease (asthma, emphysema, bronchitis), cerebrovascular disease (stroke, transient ischemic attacks), anemia and other blood dyscrasias, phlebitis, deep vein thrombosis/emboli, cancer, pregnancy, osteoporosis, musculoskeletal disorders, emotional disorders, eating disorders - Previous physical examination findings: murmurs, clicks, gallop rhythms, other abnormal heart sounds, unusual cardiac/vascular findings, abnormal pulmonary findings (wheezes, rales, crackles), high BP, edema - Laboratory findings: plasma glucose, HbA1C, hs-CRP, serum lipids and lipoproteins, other significant laboratory abnormalities - History of symptoms: discomfort (pressure, tingling sensation, pain, heaviness, burning, tightness, squeezing, numbness) in the chest, jaw, neck, back, or arms, lightheadedness, dizziness/fainting, temporary loss of visual acuity or speech, transient unilateral numbness/weakness, shortness of breath, rapid heartbeat or palpitations - especially if associated with PA, eating a large meal, emotional upset, or exposure to cold - Recent illness, hospitalization, new medical diagnoses, or surgical procedures - Orthopedic problems: arthritis, joint swelling, any condition that would make ambulation or use of certain test modalities difficult - Medication use: dietary/nutritional supplements, drug allergies - Habits: caffeine, alcohol, tobacco, recreational drug use - Exercise History: readiness to change and habitual level of activity - frequency, duration or time, type, and intensity/FITT - Work History: emphasis on current/expected physical demands, noting upper/lower extremity requirements - Family History: cardiac, pulmonary, or metabolic disease, stroke, sudden death

Blood Profile Analyses

- Multiple analyses of blood profiles may provide useful information about an individual's overall health status and ability to exercise and may help to explain certain EKG abnormalities. - Typical ranges of normal values for selected blood variables in adults (hemoglobin, hematocrit, red cell count, WBC count, etc.) - (p. 59)

American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) Risk Stratification

- Other organizations have published guidelines that address risk stratification/preparticipation PA screening - AHA and AACVPR - Exercise professionals working with patients with known CVD in exercise-based cardiac rehab and medical fitness settings are advised to use more in-depth risk stratification procedures. AACVPR risk stratification scheme may serve as a nice bridge toward offering services and programming to such "risky" or diseased clients - utilizes "lowest," "moderate," and "highest" risk patients (based on patient characteristics and nonexercise testing findings), provides recommendations for patient monitoring/exercise supervision, and for activity prescription/restriction - pp. 38-39 (However, do not consider comorbidities (e.g., Type II diabetes, morbid obesity, severe pulmonary disease, debilitating neurological/orthopedic conditions) that may require modifications for monitoring/supervision during exercise.)

Pulmonary Function

- Recommended for all smokers >45 YO and any individual presenting with dyspnea, chronic cough, wheezing, or excessive mucus production - Spirometry is simple/noninvasive and can be performed easily - indications for spirometry - (p. 60) - standards by American Thoracic Society should be followed - Measurements: forced vital capacity (FCV), forced expiratory volume in one second (FEV1.0), FEV1.0/FVC ratio, and peak expiratory flow (PEF). - FEV1.0/FVC ratio diminished with obstructive airway diseases (asthma, chronic bronchitis, emphysema, COPD) but remains normal with restrictive disorders (kyphoscoliosis, neuromuscular disease, pulmonary fibrosis, other interstitial lung diseases). - The term COPD can be used when chronic bronchitis, emphysema, or both are present and spirometry documents an obstructive effect.

PAR-Q+

- The Physical Activity Readiness Questionnaire for Everyone PAR-Q+) is used for self-guided screening or as a supplemental tool for professionals who may want additional screening resources beyond the new algorithm. - 7 YES/NO questions, designed to screen out clients from not participating in PA that may be too strenuous for them, minimal standard for entering into mod-intensity exercise programs - more effective in identifying high-risk clients - pp. 23-26

CVD Risk Factor Assessment

- Though CVD risk factor assessment is no longer a mandatory component for determining if medical clearance is warranted before individuals begin an exercise program, identifying/controlling CVD risk factors remains an important objective of disease prevention/management. - EP-C encouraged to complete a CVD risk factor analysis with patients/clients to help educate/inform the client about their need to make lifestyle modifications - Total # of positive ACSM Coronary Artery Disease Risk Factor Thresholds the person meets (if presence/absence of risk factor is not disclosed/available, it should be counted as a risk factor). Having none or one indicates a low risk of future cardiovascular disease whereas two or more risk factors indicate an increased risk of disease.

ePARmed-X Physician Clearance Follow-Up Questionnaire

- Tool that physicians can use to refer individuals to a professionally supervised PA program and make recommendations for that program as well as for medical clearance in a professionally supervised preparticipation PA screening - Designed to be used in cases where a YES on one of the 7 PAR-Q+ questions necessitates further medical clearance using the self-guided method - pp. 27-28

Health History Questionnaire

- Used to establish client's medical/health risks for participation in PA program, along with other medical/health data - pp. 30-32

3. Syncope/fainting and dizziness

Syncope/fainting and dizziness during exercise may indicate poor blood flow to the brain due to inadequate Q from a number of cardiac disorders - severe CAD, hypertrophic cardiomyopathy, aortic stenosis, malignant ventricular dysrhythmia

Physical Fitness

a set of attributes that people have or achieve that relates to the ability to perform physical activity

Physical Activity

any bodily movement produced by contracting skeletal muscles with a concomitant increase in energy expenditure

Exercise

any planned, structured, repetitive, and purposeful activity that seeks to improve or maintain any component of fitness for life or sport

Mechanism of SCD

appears to be an acute arterial insult that dislodges already present plaque, resulting in platelet aggregation or thrombosis

Health benefits of improving muscular fitness

better cardiometabolic risk factor profile, lower risk of all-cause mortality, fewer CVD events, lower risk of developing physical function limitations, lower risk for nonfatal disease, improvements in body composition, blood glucose levels, insulin sensitivity, and BP in individuals with mild-moderate HT, increase in bone mass and strength, reduction in pain/disability in those with osteoarthritis, effective in treatment of chronic back pain

Skill-Related Fitness

can also be thought of as performance-related fitness, compromises agility, balance, coordination, power, reaction time, and speed

Contraindications

clinical characteristics that have been identified/published by ACSM, generally refer to exercise testing, make PA risky and thus contraindicated

Health-Related Fitness

confined to cardiorespiratory fitness, muscular endurance, muscular strength, flexibility, and body composition

Most common causes of SCD in young individuals

congenital/hereditary abnormalities including hypertrophic cardiomyopathy, coronary artery abnormalities, and aortic stenosis * preparticipation cardiovascular screening

Participants who already exercise regularly, have a known history of CMR disease, but have no current SS (are clinically "stable") may

continue with moderate intensity exercise without medical clearance. However, if these individuals desire to progress to vigorous intensity aerobic exercise, medical clearance is recommended.

Participants who already exercise regularly and have no history or signs or symptoms of CMR disease may

continue with their current exercise volume/intensity or progress as appropriate without medical clearance.

Dynamic/Isotonic Contractions

contraction produces change in affected joint angle, gains occur across full ROM, better mimics daily activities/sport movements/functional strength

Participants who already exercise regularly but experience SS suggestive of CMR disease (regardless of disease status) should

discontinue exercise and obtain medical clearance before continuing exercise at any intensity.

8. Diabetes

fasting plasma glucose above or equal to 126 mg/dL or 2h plasma glucose values in oral glucose tolerance test (OGTT) greater or equal to 200 mg/dL or HbA1C > 6.5%. Must be at least two separate abnormal results.

Apparently healthy participants who do not currently exercise and have no history or SS of CMR disease can

immediately, and without medical clearance, initiate an exercise program at light-mod intensity. If desired, progression beyond moderate intensity should follow ACSM's principles of ex Rx.

Relative Contraindications

individuals may be accepted into a PA assessment/program if it is deemed that benefits outweigh risks

Absolute Contraindications

individuals with these biomarkers should not be allowed to participate in any form of PA program/exercise test

Preparticipation PA Screening

involves gathering and analyzing demographic and health-related information on a client along with some medical/health assessments such as the presence of signs/symptoms in order to aid decision making on a client's PA future. - dynamic process that may vary in its scope/components depending on the client's needs from a medical/health standpoint - along with cardiovascular risk factor assessment, may be the first step in a health-related physical fitness assessment.

Professionally Supervised Screening

involves interaction with an exercise professional, may involve collecting a health history on an individual (and possibly medical clearance, if warranted) while following the ACSM preparticipation PA process *Two levels aren't mutually exclusive

7. Dyslipidemia

low-density lipoprotein cholesterol (LDL-C) equal or above 130 mg/dL, HDL-C less than 40 mg/dL, or if client is taking a lipid-lowering medication. Use equal or greater than 200 mg/dL if only total blood cholesterol is available. Measurements must be assessed on at least two separate occasions.

Performance-Related Fitness

many attributes of physical fitness lend themselves to athletic performance, first subcomponent of physical fitness

4. Sedentary Lifestyle

not participating in a regular exercise program nor meeting the minimal recommendations of 30+ minutes of mod PA on 3 d/wk for at least 3 months

Participants who do not currently exercise and have (a) known CMR disease and (b) are asymptomatic should

obtain medical clearance before initiating a structured exercise program of any intensity. Following medical clearance, the individual may embark on light-mod intensity exercise and progress following guidelines.

Occupational PA

one of the largest components of PA-related EE

Decision tree for preparticipation screening - simplified algorithm

p. 32

Self-Guided Screening

performed by the individual wishing to become more physically active w/o direct input from an exercise professional

Static/Isometric Contractions

produce no change in affected joint angle, muscle strength is gained in only one joint position, gains lost quickly

6. Hypertension

resting blood pressure equal to or above 140 mmHg systolic or equal to or above 90 mmHg diastolic or if client is currently taking antihypertensive medications. Resting BPs must be assessed on at least two separate occasions.

Symptomatic participants who do not currently exercise should

seek medical clearance regardless of disease status. If signs or symptoms are present with activities of daily living, medical clearance may be urgent. Following medical clearance, the individual may embark on light-mod intensity exercise and progress as tolerated following guidelines.

7. Intermittent Claudication

severe calf pain when walking, indicating a lack of oxygenated blood flow to working muscles. CAD more prevalent in such individuals; diabetics at increased risk for this condition.

2. Dyspnea

shortness of breath at rest of with mild exertion - may indicate left ventricular dysfunction or chronic obstructive pulmonary disease

Flexibility

the ROM available at a joint

Muscular Endurance

the ability of muscle to continue to perform without fatigue

Muscular Strength

the ability of muscle to exert force

Cardiorespiratory Endurance

the ability of the circulatory and respiratory system to supply oxygen during sustained physical activity

Power

the ability or rate at which one can perform work

Agility

the ability to change the position of the body in space with speed and accuracy

Speed

the ability to perform a movement within a short period of time

Coordination

the ability to use the senses, such as sight and hearing, together with body parts in performing tasks smoothly and accurately

Balance

the maintenance of equilibrium while stationary or moving

Body Composition

the relative amounts of muscle, fat, bone, and other vital parts of the body

Reaction Time

the time elapsed between stimulation and the beginning of the reaction to it

8. Heart Murmers

unusual sounds caused by blood flowing through the heart - may indicate valvular or other cardiovascular disease. Especially important to exclude hypertrophic cardiomyopathy and aortic stenosis as underlying causes because these are among the more common causes of exertion-related SCD.

Participant Instructions

- Written instructions along with a description of the preexercise evaluation should be provided well in advance of the appointment so the client can prepare adequately - Points to be considered for inclusion in such preliminary instructions: - Refrain from ingesting food, alcohol, or caffeine or using tobacco within at least 3 h of testing - Rested for assessment, avoiding significant exertion or exercise on the assessment day - Clothing that permits freedom of movement, including walking/running shoes. Women should bring a loose-fitting, short-sleeved blouse that buttons down the front and should avoid restrictive undergarments. - If an outpatient evaluation, participants should be made aware that the exercise test may be fatiguing and they may wish to have someone drive them home. - If the test is for diagnostic purposes, may be helpful to have participant discontinue prescribed cardiovascular medications - only with physician approval - as prescribed antianginal agents alter the hemodynamic response to exercise and significantly reduce the sensitivity of EKG changes for ischemia. Patients could taper beta-blocking agents over 2-4 days to minimize hyperadrenergic withdrawal symptoms. - If exercise test is for functional exercise purposes, patients should continue their medication regimen on their usual schedule so that the exercise responses will be consistent with responses expected during training. - Should bring a list of their medications including dosage/frequency and should report last dose taken. - Drink ample fluids over the 24 hour period prior to test to ensure ample hydration

Methods for quantifying relative intensity of PA

- percent of VO2R (oxygen uptake reserve) - percent of HRR - percent of VO2 (oxygen consumption) - METs

Preparticipation PA Screening Process (for general, nonclinical population)

1) past PA history/current level of PA (use HHQ or questioning) 2) evaluated for presence of known CMR disease (HHQ or questioning) 3) assessment of presence of SS suggestive of CMR (cardiac, peripheral vascular, cerebrovascular, types I and II diabetes, and renal diseases) 4) desired exercise intensity - Note: The process of ACSM preparticipation PA screening has been divorced from the concept of the need for and supervisory qualifications of a graded exercise test and other health-related physical fitness assessments. - Exercise preparticipation health screening checklist - p. 33

Atherosclerotic CVD Risk Factors and Defining Criteria

1. age 2. family history 3. smoking 4. sedentary lifestyle 5. obesity 6. hypertension 7. dyslipidemia 8. diabetes 9. HDL-C (+ risk factor)

Moderate Intensity

3.0-5.9 METs (p. 5)

Vigorous Intensity

6.0+ METs (p. 5)

Very Light/Light Intensity

< 3.0 METs (p. 5)

Woman, age 36 yr, nonsmoker. Height = 64 in, weight = 108 lbs, BMI = 18.5 kg/m2. RHR = 61 bpm, resting BP = 142/86 mmHg. TC = 174 mg/dL, blood glucose normal with insulin injections. Type I diabetes diagnosed at age 7 yr. Teaches dance aerobic classes three times a week, walks approximately 45 min four times a week. Both parents are in god health with no history of CVD.

Age? NO Fam History? NO Smoking? NO Physical Inactivity? NO Obesity? NO HT? YES Dyslipidemia? NO Diabetes? YES HDL-C? NO TWO RISK FACTORS

Man, age 44 yr, nonsmoker. Height = 70 in, weight = 216 lbs, BMI = 31.0 kg/m2. RHR = 62 beat/min, resting BP = 124/84 mmHg. Total serum cholesterol = 184 mg/dL, LDL-C = 106 mg/dL, HDL-C = 44 mg/dL, FBG = 130 mg/dL. Reports that he doesn't have time to exercise. Father had type II diabetes and died at age 67 YO of a heart attack; mother living, no CVD. No medications.

Age? NO Fam History? NO Smoking? NO Physical Inactivity? YES Obesity? YES HT? NO Dyslipidemia? NO Diabetes? YES HDL-C? NO THREE RISK FACTORS

Female, age 21yr, smokes socially on weekends (about 10-20 cigarettes). Drinks alcohol one or two nights a week, usually on weekends. Height = 63 in, weight = 124 lbs, BMI = 22.0 kg/m2. RHR = 76 bpm, resting BP = 118/72 mmHg. TC = 178 mg/dL, LDL-C = 98 mg/dL, HDL-C = 62 mg/dL, FBG = 96 mg/dL. Currently taking oral contraceptives. Attends group exercise class two to three times a week. Both parents living and in good health.

Age? NO Fam History? NO Smoking? YES Physical Inactivity? NO Obesity? NO HT? NO Dyslipidemia? NO Diabetes? NO HDL-C? YES ZERO RISK FACTORS

Man, age 45 yr, nonsmoker. Height = 72 in, weight = 168 lb, BMI = 22.8 kg/m2. RHR = 64 bpm, resting BP = 124/78 mmHg. TC = 187 mg/dL, LDL-C = 103 mg/L, HDL-C = 39 mg/dL, FBG = 88 mg/dL. Recreationally competitive runner, runs 4-7 d/wk, completes one to two marathons and numerous other road races every year. No medications other than over-the-counter ibuprofen as needed. Father died at age 51 YO of a heart attack; mother died at age 81 YO of cancer.

Age? YES Fam History? YES Smoking? NO Physical Inactivity? NO Obesity? NO HT? NO Dyslipidemia? YES Diabetes? NO HDL-C? NO THREE RISK FACTORS