ACSM Guidelines for Exercise Testing and Prescription, 8th Edition

Known Heart Murmur

Although some may be innocent, heart murmurs may indicate valvular or other cardiovascular disease.

Unusual fatigue or shortness of breath with usual activities

Although there may be benign origins for these symptoms, they also may signal the onset of, or change in the status of cardiovascular, pulmonary, or metabolic disease.

Medical Exam for Low Risk

Asymptomatic (defined as showing no symptoms) men and women with less than one risk factor participating in moderate to vigorous exercise do not necessarily need a medical exam or have medical supervision before, during, or after exercise.

Medical Exam for Moderate Risk

Asymptomatic men and women with one or more risk factors participating in moderate to vigorous exercise should receive a medical exam and possibly medical supervision for all vigorous exercise programs (not necessary for moderate exercise programs).

Ankle Edema

Bilateral ankle edema that is most evident at night is a characteristic sign of heart failure or bilateral chronic venous insufficiency. Unilateral edema of a limb often results from venous thrombosis or lymphatic blockage in the limb. Generalized edema occurs in persons with the nephrotic syndrome, severe heart failure, or hepatic cirrhosis.

Risk Stratification: Obesity

Body mass index equal or greater than 30, or waist girth greater than 102 cm (40 inches) for men and greater than 88 cm (35 inches) for women.

Risk Stratification: Cigarette Smoking

Current cigarette smoker or those who quit within the previous 6 months or exposure to environmental tobacco smoke.

Pulmonary Disease Diagnosis

Diagnosed with chronic obstructive pulmonary disease (COPD), asthma, interstitial lung disease, or cystic fibrosis.

Metabolic Disease Diagnosis

Diagnosed with diabetes mellitus (type 1 or type 2), thyroid disorders, and renal or liver disease.

Cardiovascular Disease (C.V.D.) Diagnosis

Diagnosed with one of the following conditions: Cardiac, peripheral artery (PAD), or cerebrovascular disease.

Risk Stratification: Dyslipidemia

Dyslipidemia is defined as an abnormal amount of lipids (e.g. cholesterol and/or fat) in the blood. Low-density lipoprotein (LDL-C) cholesterol equal or greater than 130, or high-density lipoprotein (HDL-C) cholesterol less than 40.

Shortness of breath at rest or with mild exertion

Dyspnea (defined as an abnormally uncomfortable awareness of breathing) is one of the principle symptoms of cardiac and pulmonary disease. It commonly occurs during strenuous exertion in healthy, untrained persons; however, it should be regarded as abnormal when it occurs at a level of exertion that is not expected to evoke this symptom in a given individual. Abnormal exertional dyspnea suggests the presence of cardiopulmonary disorders, in particular left ventricular dysfunction or chronic obstructive pulmonary disease.

Risk Stratification (Negative): High-serum HDL Cholesterol

Equal or greater than 60.

Risk Stratification: Prediabetes

Impaired fasting glucose (IFG) equal of greater than 100, but less than 126.

Medical Exam for High Risk

Men and women with symptomatic, or known cardiac, pulmonary, or metabolic disease should have a medical exam and possibly medical supervision when participating in a moderate or vigorous exercise program.

Risk Stratification: Age

Men equal or greater than 45 years old; Women equal or greater than 55 years old.

mg/dL

Milligram per deciliter

mmol/L

Millimole per liter.

Risk Stratification: Family History

Myocardial infraction (defined as destruction of heart tissue resulting from obstruction of the blood supply to the heart muscle), coronary revascularization (defined as the process of restoring blood flow to the heart), or sudden death before 55 years of age in the father or other male first-degree relative, or before 65 years of age in the mother or other female first-degree relative.

Risk Stratification: Sedentary Lifestyle

Not participating in at least 30 min of moderate intensity (40%-60% of VO2R) physical activity on a least three days of the week for at least three months.

Pain, discomfort, in the chest, neck, jaw, arms, or other areas that may result from ischemia (an inadequate blood supply to an organ or part of the body, esp. the heart muscles)

One of the cardinal manifestations of cardiac disease, in particular coronary artery disease. Key features favoring an ischemic origin include: constricting, squeezing, burning, "heaviness" or "heavy feeling". Located in the substernal, across midthorax, anteriorly; in one or both arms, shoulders; in neck, cheeks, teeth; in forearms, fingers in the interscapular region. Often provoked by exercise or exertion, excitement, other forms of stress, cold weather, and occurrence after meals.

Orthopnea or paroxysmal nocturnal dyspnea

Orthopnea refers to dyspnea occurring at rest in the recumbent position that is relieved promptly by sitting upright or standing. Paroxysmal nocturnal dyspnea refers to dyspnea, beginning usually 2-5 hours after the onset of sleep, which may be relieved by sitting on the side of the bed or getting out of bed. Both are symptoms of left ventricular dysfunction.

Palpitations or tachycardia

Palpitations (defined as an unpleasant awareness of the forceful or rapid beating of the heart) may be induced by various disorders or cardiac rhythm. These include: tachycardia, bradycardia of sudden onset, ectopic beats, compensatory pauses, and accentuated stroke volume resulting from valvular regurgitation. Palpitations also often result from any anxiety states and high cardiac output states, such as anemia, fever, etc.

Intermittent Claudication

Refers to the pain that occurs in a muscle with an inadequate blood supply that is stressed by exercise. The pain does not occur with standing or sitting, is reproducible from day to day, is more severe when walking upstairs or up a hill, and is often described as a cramp, which disappears within 1-2 minutes after stopping exercise. Coronary artery disease is more prevalent in persons with intermittent claudication. Patients with diabetes are at increased risk for this condition.

Dizziness or syncope (a temporary loss of consciousness caused by a fall in blood pressure)

Syncope is most commonly caused by a reduced perfusion of the brain. Dizziness and, in particular, syncope during exercise may result from cardiac disorders that prevent the normal rise (or an actual fall) in cardiac output.

Risk Stratification: Hypertension

Systolic blood pressure (SBP) equal or greater than 140 mm Hg and/or diastolic (DBP) equal or greater than 90 mm Hg, confirmed by measurements on at least two separate occasions.

Risk Stratification

The process by which individuals are assigned to a risk category of low, moderate, or high based on: The presence or absence of known cardiovascular, pulmonary, and/or metabolic disease. The presence or absence of signs or symptoms suggestive of cardiovascular, pulmonary, and/or metabolic disease. The presence or absence of C.V.D. risk factors.

Moderate Risk

Those individuals who do not have signs/symptoms of or diagnosed cardiovascular, pulmonary, and/or metabolic disease, but have two or more C.V.D. risk factors.

Low Risk

Those individuals who do not have signs/symptoms of or have diagnosed cardiovascular, pulmonary, and/or metabolic disease and have no more than one C.V.D. risk factor.

High Risk

Those individuals who have one or more signs/symptoms of or diagnosed cardiovascular, pulmonary, and/or metabolic disease.