PP 2: Preliminary Screening and Risk Classification

What are the ACSM Preparticipation Screening Algorithm Components

ACSM Preparticipation Screening Algorithm Components • Classifying individuals who do / do not currently participate in regular exercise • ID individuals with known CV, metabolic, or renal diseases or those with s/s (signs and symptoms) suggestive of cardiac, peripheral vascular, or cerebrovascular disease, Types 1 and 2 diabetes mellitus and renal disease • ID desired exercise intensity

CVD risk factors

Age, family history, smoking, sedentary, obesity, hypertension, dyslipidemia, prediabetes

Position of PT when heart rate is taken should be...

sitting, at rest

How long should we count to measure HR

15-60 secs

Self-Guided Methods

- Initiated and guided by individuals - Little or no supervision or input from exercise or health professional May complete of their own accord "previously inactive men over 40 yr and women over 50 yr, and people at high risk for CVD should first consult a physician before embarking on a program of vigorous physical activity to which they are not accustomed"- Surgeon General's Report on Physical Activity and Health - Others that may be incorporated Routine paperwork Entry procedures at health/fitness or clinical exercise program facilities PA promotional materials to the general public - May need to obtain medical clearance - Preparticipation health screening by self-reported medical history or health risk appraisal should be done all individuals wishing to initiate a physical activity program Easily accomplished by using the Par-Q+

Normal HR

60-100 bpm

Although RT is - in popularity, current evidence is - regarding CV complications during RT to warrant formal prescreening recommendations

Although RT is ↑ in popularity, current evidence is insufficient regarding CV complications during RT to warrant formal prescreening recommendations

CVD risk factor-based exercise preparticipation health screening may be - due to the high prevalence of risk factors and may lead to -

CVD risk factor-based exercise preparticipation health screening may be overly conservative due to the high prevalence of risk factors and may lead to excessive physician referrals, particularly in older adults • Exercise professionals are encouraged to complete a CVD risk factor assessment with their patients/clients as part of the preexercise evaluation

American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) Risk Stratification Criteria for Patients with Cardiovascular Disease- Highest Risk Characteristics of patients at high risk for exercise participation (any one or combination of these findings places a patient at high risk)

Characteristics of patients at high risk for exercise participation (any one or combination of these findings places a patient at high risk) • Presence of complex ventricular dysrhythmias during exercise testing or recovery • Presence of angina or other significant symptoms (e.g., unusual shortness of breath, light-headedness, or dizziness at low levels of exertion [<5 METs] or during recovery) • High level of silent ischemia (ST-segment depression ≥2 mm from baseline) during exercise testing or recovery • Presence of abnormal hemodynamics with exercise testing (i.e., chronotropic incompetence or flat or decreasing systolic BP with increasing workloads) or recovery (i.e., severe postexercise hypotension)

American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) Risk Stratification Criteria for Patients with Cardiovascular Disease- Lowest Risk Characteristics of patients at lowest risk for exercise participation (all characteristics listed must be present for patients to remain at lowest risk)

Characteristics of patients at lowest risk for exercise participation (all characteristics listed must be present for patients to remain at lowest risk) • Absence of complex ventricular dysrhythmias during exercise testing and recovery • Absence of angina or other significant symptoms (e.g., unusual shortness of breath, light-headedness, or dizziness, during exercise testing and recovery) • Presence of normal hemodynamics during exercise testing and recovery (i.e., appropriate increases and decreases in heart rate and systolic blood pressure with increasing workloads and recovery) • Functional capacity ≥7 metabolic equivalents (METs)

American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) Risk Stratification Criteria for Patients with Cardiovascular Disease- Moderate Risk Characteristics of patients at moderate risk for exercise participation (any one or combination of these findings places a patient at moderate risk)

Characteristics of patients at moderate risk for exercise participation (any one or combination of these findings places a patient at moderate risk) • Presence of angina or other significant symptoms (e.g., unusual shortness of breath, light-headedness, or dizziness occurring only at high levels of exertion [≥7 METs]) • Mild to moderate level of silent ischemia during exercise testing or recovery (ST-segment depression <2 mm from baseline) • Functional capacity <5 METs

Consent should be - explained Statement indicating - Note -

Consent form should be verbally explained • Statement indicating that the patient has been given an opportunity to ask questions about the procedure and has sufficient information to give informed consent • Note specific questions from the participant on the form along with the responses provided

American College of Sports Medicine Preparticipation Screening Algorithm

Designed to ID participants at risk for CV complications during / immediately after aerobicexercise

Why do we do preliminary screening and risk classification

Documented risks along with benefits ID individuals... Who should receive medical clearance before initiating an exercise program or ↑ the frequency, intensity, and/or volume of their current program With clinically significant disease/s who may benefit from participating in a medically supervised exercise program With medical conditions that may require exclusion from exercise programs until those conditions are abated or better controlled Recognize special needs of individuals that may affect exercise testing and programming

General Participant Instructions

Explicit instructions for participants before exercise testing ↑ test validity and data accuracy • Refrain from ingesting food, alcohol, caffeine or using tobacco products within 3 h of testing • Participants should be rested for the assessment, avoiding significant exertion or exercise on the day of the assessment • Clothing should permit freedom of movement and include walking or running shoes Women should bring a loose fitting, short-sleeved blouse that buttons down the front and should avoid restrictive undergarments.

True or False: It is optional for the consent form to indicate the participant is free to withdraw at any time that

False • The consent form must indicate the participant is free to withdraw at any time that

What is the cornerstone of antihypertensive therapy (BP)

Lifestyle modification is the cornerstone of antihypertensive therapy: • PA • Weight reduction (if needed) • DASH eating plan (i.e., a diet rich in fruits, vegetables, and low-fat dairy products with a ↓ content of saturated and total fat), dietary sodium reduction (<2 g sodium/d) • Moderation of alcohol consumption

American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) Risk Stratification Criteria for Patients with Cardiovascular Disease- Moderate Risk Nonexercise Testing Findings

Nonexercise Testing Findings • Rest ejection fraction 40% to 49%

American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) Risk Stratification Criteria for Patients with Cardiovascular Disease- Highest Risk Nonexercise Testing Findings

Nonexercise Testing Findings • Rest ejection fraction <40% • History of cardiac arrest or sudden death • Complex dysrhythmias at rest • Complicated myocardial infarction or revascularization procedure • Presence of congestive heart failure • Presence of signs or symptoms of postevent/postprocedure ischemia • Presence of clinical depression

American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) Risk Stratification Criteria for Patients with Cardiovascular Disease- Lowest Risk Nonexercise Testing Findings

Nonexercise Testing Findings • Resting ejection fraction ≥50% • Uncomplicated myocardial infarction or revascularization procedure • Absence of complicated ventricular dysrhythmias at rest • Absence of congestive heart failure • Absence of signs or symptoms of postevent/postprocedure ischemia • Absence of clinical depression

BP classifications

Normal: Less than 120/80 Elevated: Systolic b/t 120-129 and Diastolic less than 80 Stage 1 Hypertension: Systolic 130-139 or Diastolic less b/t 80-89 Stage 2 Hypertension: Systolic at least 140 or Diastolic at least 90 Hypertensive Crisis: Systolic over 180 and/or Diastolic over 120

Preparticipation health screening process

Preparticipation health screening before initiating PA or an exercise program is a two-stage process: 1.) The need for medical clearance before initiating / progressing exercise programming is determined using the updated / revised ACSM screening algorithm a) In the absence of professional assistance, interested individuals may use self-guided methods 2.) If indicated during screening, medical clearance should be sought from an appropriate health care provider a) The manner of clearance should be determined by the clinical judgement and discretion of the health care provider

Self-guided methods may ID those who...

Self-guided methods may ID those who need further consultation

The healthier populations typically encountered in the health fitness setting generally warrant a (more or less) intensive approach to the preexercise evaluation

The healthier populations typically encountered in the health fitness setting generally warrant a MORE intensive approach to the preexercise evaluation

The new preparticipation health screening process is based on...

The new preparticipation health screening process is based on... 1.) The individual's current level of structured physical activity 2.) The presence of major signs or symptoms suggestive of CV, metabolic, or renal diseases 3.) The desired exercise intensity

True or False: The content and extent of consent forms may vary

True • Enough information must be present in the informed consent process to ensure that the participant knows and understands the purposes and risks associated with the test or exercise program in health/fitness or clinical settings

True or False: If the participant is a minor, a legal guardian or parent must sign the consent form

True • If the participant is a minor, a legal guardian or parent must sign the consent form

Informed Consent What should happen when the exercise test is for purposes other than diagnosis or Ex RX?

When the exercise test is for purposes other than diagnosis or Ex RX (i.e., for experimental purposes), this should be indicated during the consent process and reflected on the informed consent form, and applicable policies for the testing of human subjects must be implemented

Patient Privacy: Informed Consent

• All reasonable efforts must be made to protect the privacy of the patient's health information (e.g., medical history, test results) as described in the Health Insurance Portability and Accountability Act (HIPAA) of 1996

Informed Consent Because most consent forms include the statement "emergency procedures and equipment are available, what must that program provide?

• Because most consent forms include the statement "emergency procedures and equipment are available," the program must ensure available personnel are appropriately trained and authorized to carry out emergency procedures that use such equipment

Updated preparticipation process based on the outcomes of a scientific roundtable sponsored by ACSM in 2014

• The relative risk of a CV event is transiently ↑ during vigorous intensity exercise (compared to rest) but the absolute risk of an exercise-related acute cardiac event is low in healthy asymptomatic individuals • Among adults, the risk for activity associated SCD and AMI is highest among those with underlying CVD who perform unaccustomed vigorous PA.

Components of the Physical Exam

• Body weight; determination of body mass index, waist girth, and/or body composition • Apical pulse rate and rhythm • Resting blood pressure: seated, supine, and standing • Auscultation of the lungs with specific attention to uniformity of breath sounds in all areas (absence of rales, wheezes, and other breathing sounds) • Palpation of the cardiac apical impulse and point of maximal impulse • Auscultation of the heart with specific attention to murmurs, gallops, clicks, and rubs • Palpation and auscultation of carotid, abdominal, and femoral arteries • Evaluation of the abdomen for bowel sounds, masses, visceromegaly, and tenderness • Palpation and inspection of lower extremities for edema and presence of arterial pulses • Absence or presence of tendon xanthoma and skin xanthelasma • Follow-up examination related to orthopedic or other medical conditions that would limit exercise testing • Tests of neurologic function including reflexes and cognition (as indicated) • Inspection of the skin, especially of the lower extremities in known patients with diabetes mellitus

Risk Stratification for Patients in Cardiac Rehabilitation and Medical Fitness Facilities

• Exercise professionals working with patients with known CVD in exercise-based cardiac rehabilitation and medical fitness settings are advised to use more in-depth risk stratification procedures

Commonly used spirometry measurements

• Forced vital capacity (FVC) • Forced expiratory volume in one second (FEV1.0) • FEV1.0/FVC ratio* • Peak expiratory flow (PEF)

Participant Instructions If the evaluation is on an outpatient basis, participants should be made aware that...

• If the evaluation is on an outpatient basis, participants should be made aware that the exercise test may be fatiguing and that they may wish to have someone accompany them to the assessment to drive them home afterward.

Participant Instructions If the exercise test is for diagnostic purposes, it may be helpful for patients to...

• If the exercise test is for diagnostic purposes, it may be helpful for patients to discontinue prescribed cardiovascular medications, but only with physician approval. Currently prescribed antianginal agents alter the hemodynamic response to exercise and significantly reduce the sensitivity of ECG changes for ischemia. Patients taking intermediate- or high-dose β-blocking agents may be asked to taper their medication over a 2- to 4-d period to minimize hyperadrenergic withdrawal responses.

Participant Instructions If the test is for functional or Ex Rx purposes, patients should...

• If the test is for functional or Ex Rx purposes, patients should continue their medication regimenon their usual schedule so that the exercise responses will be consistent with responses expected during exercise training.

True or False: There is sufficient evidence to suggest that the presence of CVD risk factors without underlying disease confers substantial risk of adverse exercise-related CV events

• Insufficient evidence is available to suggest that the presence of CVD risk factors without underlying disease confers substantial risk of adverse exercise-related CV events

How do you check to see what is acceptable for the consent process

• It is advisable to check with authoritative bodies (e.g., hospital risk management, institutional review boards, facility legal counsel) to determine what is appropriate for an acceptable informed consent process

Components of the Medical History

• Medical diagnosis • Previous physical examination findings • Laboratory findings • History of symptoms • Recent illness, hospitalization, new medical diagnoses, or surgical procedures • Orthopedic problems • Medication use including supplements and drug allergies • Other habits including caffeine, alcohol, tobacco, or drug use • Exercise history • Work history • Family history

Informed Consent Who needs to approve sample form adoptions for Informed Consents?

• No sample form should be adopted for a specific test or program unless approved by local legal counsel and/or the appropriate institutional review board

Is informed consent necessary?

• Obtaining adequate informed consent from participants before exercise testing and participation in an exercise program is an important ethical and legal consideration

Major Signs or Symptoms Suggestive of Cardiovascular, Metabolic and Renal Disease

• Pain; discomfort (or other anginal equivalent) in the chest, neck, jaw, arms, or other areas that may result from ischemia • Shortness of breath at rest or with mild exertion • Dizziness or syncope • Orthopnea or paroxysmal nocturnal dyspnea • Ankle edema • Palpitations or tachycardia • Intermittent claudication • Known heart murmur • Unusual fatigue or shortness of breath with usual activities

Participant Instructions Participants should bring a list of their - including - and - to the assessment and should report the -. As an alternative, participants may wish to bring their - with them for the exercise testing staff to record.

• Participants should bring a list of their medications including dosage and frequency of administration to the assessment and should report the last actual dose taken. As an alternative, participants may wish to bring their medications with them for the exercise testing staff to record.

Participant Instructions What is important for the pts to do over the 24 hrs before the testing?

• Participants should drink ample fluids over the 24-h period preceding the test to ensure normal hydration before testing.

Pulmonary function testing with spirometry is recommended for all - and in any individual presenting with: - - - -

• Pulmonary function testing with spirometry is recommended for all smokers >45 yr and in any individual presenting with: • Dyspnea (shortness of breath) • Chronic cough • Wheezing • Excessive mucus production

How do we preliminary screen?

• Self guided screening (i.e. ParQ) • Professionally guided screening

Informed Consent How often should emergency drills be performed?

• Written emergency policies and procedures should be in place, and emergency drills should be practiced at least once every 3 mo or more often when there is a change in staff