3. Preparticipation Health Screening
CVD Risk Factors: Family History
Family History (parents, sibs, kids, First degree family member) Male before 55 Female before 65
CVD Risk Factors: Dyslipidemia
TC > 200 mg.dL-1 (If only available) LDL>130 mg.dL-1 Or HDL <40 mg.dL-1 Or Lipid lowering meds.
CVD Negative Risk Facctors
High HDL >60 mg.dL-1
Professionally Guided Screening for Physical Activity
"Professionally guided" implies that the health fitness/clinical assessment is conducted by, and the exercise program is designed and supervised by, appropriately trained personnel that possess academic training and practical/clinical knowledge, skills, and abilities commensurate with the credentials defined in Appendix D.
CVD Risk Factors: Sedentary Lifestyle
<30 mins mod., <3 days/wk, <3 months < Moderate Intensity
CVD Risk Factors: Hypertension
>140/90 Antihypertensive meds.
preexercise test evaluation
A comprehensive preexercise test evaluation in the clinical setting generally includes a medical history, a physical examination, and laboratory tests A preexercise evaluation that includes a physical examination, an exercise test, and/or laboratory tests may be warranted for lower risk individuals whenever the health/fitness and clinical exercise professional has concerns about an individual's CVD risk requires additional information to design an Ex Rx or when the exercise participant has concerns about starting an exercise program of any intensity without medical evaluation.
CVD Risk Factors: AGE
Age Men >45 Women >55
Physical Examination
Anthropometrics Pulse rate and rhythm Resting blood pressure Palpitation of pulses Auscultation of lungs Evaluation of abdomen Evaluation of lower extremities Follow-up of prior condition Neurologic function Inspection of skin
CVD Risk Factors: Obesity
BMI>30 kg.m-2 Men: Waist >40 in or >102 cm Women: Waist >35 in or >88 cm
Appropriate components of the physical examination may include the following:
Body weight Determination of BMI, waist girth, and/or body is desirable Apical pulse rate and rhythm Resting BP: 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
Pain, discomfort (or anginal equivalent) that may result from ischemia: Signs or Symptoms Suggestive of CVD,
Character: Constricting, squeezing, burning, "heaviness" Location: substernal, anteriorly, one or both arms, neck, teeth, forearm, interscapular region Provoking Factors: exercise/exertion, excitement, stress, etc. Key Features AGAINST ischemia Character: dull ache, "knife like", sharp, stabbing, etc Location: left submammary area, left hemithorax Provoking Factors: after completing exercise, specific body motion
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) 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) Nonexercise Testing Findings Resting ejection fraction ≥50% Uncomplicated myocardial infarction or revascularization procedure Absence of complicated ventricular dysrhythmias at rest Absence of CHF Absence of signs or symptoms of postevent/postprocedure ischemia Absence of clinical depression
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) 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 Nonexercise Testing Findings Rest ejection fraction 40% to 49%
Algorithm components
Classifying individuals who do or do not currently participate in regular exercise Identifying individuals with known CV, metabolic, or renal diseases or those with signs or symptoms suggestive of cardiac, peripheral vascular, or cerebrovascular disease, Types 1 and 2 diabetes mellitus (DM), and renal disease Identifying desired exercise intensity
CVD Risk Factors: Cigarette Smoking
Current or quit <6 months Environment
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 Risk stratification criteria from the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) are presented in Box 2.2
Commonly used spirometry measurements:
Forced vital capacity (FVC) - Deep breath and blow out as fast as you can. Forced expiratory volume in one second (FEV1.0) FEV1.0/FVC ratio - healthy about 80% Peak expiratory flow (PEF) The FEV1.0/FVC is diminished with obstructive airway diseases (e.g., asthma, chronic bronchitis, emphysema, chronic obstructive pulmonary disease [COPD], smoking). However, it remains normal with restrictive disorders (e.g., kyphoscoliosis, neuromuscular disease, pulmonary fibrosis, other interstitial lung diseases).
Purpose of a Health Appraisal
Identify individuals with medical contraindications that require exclusion from exercise programs until those conditions have been abated or controlled. Identify individuals with clinically significant diseases/conditions requires a medically supervised exercise program. Identify individuals at increased risk for disease and need further medical evaluation Age, symptoms, other risk factors, etc.
Participant Instructions for Exercise Testing (cont.)
If the exercise test is for diagnostic purposes, it may be helpful for patients to discontinue prescribed cardiovascular medications, but only with physician approval. Medications can alter the physiological response and the participants perception of the exercise If the test is for functional or exercise prescription purposes, patients should continue their medication regimen on their usual schedule so that the exercise responses will be consistent with responses expected during exercise training.
CVD Risk Factors: Prediabetes
Impaired Fasting Glucose (IFG) >100 mg.dL-1 but <125 mg.dL-1 Or Impaired Glucose Tolerance (2hr values) >140 mg.dL-1 but <199 mg.dL-1
Evaluating Health Status Categories
M-edical history review R-isk factor assessment and stratification P-rescribed medications L-evel of physical activity E-stablish if physician consent is necessary A-dminister fitness tests and evaluate results S-et up exercise prescription E-valuate progress with follow-up test(s) A comprehensive pre-exercise test evaluation in the clinical setting generally includes a medical history, a physical examination, and laboratory tests.
Medical History
Medical Diagnosis Previous findings History of symptoms Recent medical issues Orthopedic problems Medications Habits Exercise history Work history Family history
Medical History, Physical Examination, and Laboratory Tests
Medical diagnosis Previous physical examination 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
ACSM Preparticipation Screening Algorithm
New instrument designed to identify participants at risk for CV complications during or immediately after aerobic exercise Although resistance training is growing in popularity, current evidence is insufficient regarding CV complications during resistance training to warrant formal prescreening recommendations CV complications during resistance training, this risk cannot currently be determined but appears to be low
Participant Instructions for Exercise Testing
No food, alcohol, or 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. Participants may want someone to drive them home.
Informed Consent
Obtained before exercise testing and participation in an exercise program Important ethical step Enough information must be present in the informed consent to ensure that the participant knows and understands the purposes and risks associated with the test or exercise program. Verbally explained and include a 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. The participant is free to withdraw from the procedure at any time. If the participant is a minor, a legal guardian or parent must sign the consent form. Verbal or written assent?? It is advisable to check with authoritative bodies (e.g., hospital risk management, IRB, facility legal counsel) to determine what is appropriate for an acceptable informed consent process Template provided? 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. Consult with appropriate local legal counsel and/or the appropriate IRB. When the exercise test is for purposes other than diagnosis or exercise prescription (i.e., for experimental purposes), this should be indicated during the consent process and applicable policies for the testing of human subjects must be implemented.
Preparticipation Screening
Par-Q Health Status Questionnaire Risk Stratification? Physician Consent Exercise Test
Participant Instructions (cont.)
Participants should bring a list of their medications including dosage and frequency of administration Or simply have them bring their medication with them! Participants should be hydrated well!!
Procedures for Assessment of Resting Blood Pressure
Patients should be seated quietly for at least 5 min in a chair with back support (rather than on an examination table) with their feet on the floor and their arms supported at heart level. Patients should refrain from smoking cigarettes or ingesting caffeine for at least 30 min preceding the measurement. 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. The appropriate cuff size must be used to ensure accurate measurement. The bladder within the cuff should encircle at least 80% of the upper arm. Many adults require a large adult cuff. Place stethoscope chest piece below the antecubital space over the brachial artery. Bell and diaphragm side of chest piece appear equally effective in assessing BP.
Lifestyle modification is the cornerstone of antihypertensive therapy:
Physical activity Weight reduction (if needed) DASH eating plan (i.e., a diet rich in fruits, vegetables, and low-fat dairy products with a reduced content of saturated and total fat), dietary sodium reduction (no more than 100 mmol or 2.4 g sodium·d−1) Moderation of alcohol consumption (1-2 per day)
Self-Guided Methods
Preparticipation health screening by self-reported medical history or health risk appraisal should be done for all individuals wishing to initiate a physical activity program. This self-guided method can be easily accomplished by using the PAR-Q+
Pulmonary Function
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, or excessive mucus production. Spirometric testing is also valuable in identifying patients with chronic disease (i.e., COPD and heart failure) with diminished pulmonary function that may benefit from an inspiratory muscle training program.
Informed Consent Form for Exercise Test
Purpose and Explanation Potential Risks and Discomforts Responsibilities of the Participant Benefits Inquiries Protection of Medical Records Freedom of Consent
The professionally guided pre-participation screening process involves
Review of more detailed health/medical history information Specific risk stratification Detailed recommendations for physical activity/exercise, medical examination, exercise testing, and physician supervision.
Major Signs or Symptoms Suggestive of CVD, Metabolic, or Renal Disease
Shortness of breath at rest or with mild exertion (Dyspnea) Dizziness or syncope (Loss of consciousness) Orthopnea or paroxysmal noctural dyspnea Ankle edema Palpitations or tachycardia Intermittent claudication Slowing of blood flow Known heart murmur Unusual fatigue or shortness of breath with usual activities
The new preparticipation health screening process is based on
The individual's current level of structured physical activity The presence of major signs or symptoms suggestive of CV, metabolic, or renal diseases (Table 2.1) The desired exercise intensity
Preparticipation health screening before initiating PA or an exercise program is a two-stage process:
The need for medical clearance before initiating or progressing exercise programming is determined using the updated and revised ACSM screening algorithm In the absence of professional assistance, interested individuals may use self-guided methods If indicated during screening, medical clearance should be sought from an appropriate health care provider The manner of clearance should be determined by the clinical judgment and discretion of the health care provider