Pre-Screening and Risk Stratification
Chapter 1, 2 and 3 ACSM
What is involved in the pre- screening process ?
The Basic Goal – To
determine if it is safe for an
individual to start an
exercise program, what
type of exercise testing is
appropriate, and what
medical supervision is
necessary.
What is the process?
1. If in a clinical setting, obtain informed consent.
2. A form of medical and health history
3. What goals for activity does the person have?
(this is important !!!) 4. Risk Stratify the client.
5. Decided whether it is recommended to do a physical exam, exercise test the person, AND what type of test is appropriate.
6. Decide if your facility can test the person by…..
Documentation
Results of screening
Document communication with healthcare professionals
Physician referral form
Exercise prescription
Emergency procedures
Pre-participation Screening
Informed Consent (pg 52 example)
PAR-Q* - minimal standard
Physical Exam findings
Lung sounds
Heart sounds
Laboratory Tests
Blood
Blood pressure
Pulmonary Function
Informed Consent
Should be conveyed both verbally and written
Explanation of procedure/program
Risks & Benefits
Responsibilities of participant
Confidentiality (lock and key)
Documentation of questions and answers
Documentation of acceptance
Freedom of consent (sign and initial)
Other Forms
Assumption of Risk form
Potential client declines to complete screening forms but still wants to participate
Physician’s approval form (medical clearance)
Emergency Medical Authorization - minors
In chapter 3 it discuses the exercise program and how you should present a
consent and explain to the participants that they may stop if they want to.
What do you do in a case that they do not want to stop but you see the test
may bring bodily harm?
Medical History
Diagnoses
Hospitalizations/ Surgery
Medications (action, dose)
Taking meds regularly
Family Hx
Risk Factors*
Current Physical Activity Hx
Previous exercise test findings
Frequency, Type, signs and symptoms (SxS) – (Box 2-1)
Veteran’s Specific Activity Questionnaire
Pre-participation Screening
Risk Factors (Table 2-2) KNOW!!!!!!!!
Family History
Cigarette Smoking
Hypertension
Hypercholesterolemia
Impaired fasting glucose
Obesity
Sedentary lifestyle
Negative Risk Factor
High serum HDL
Pre-participation Screening (con’t)
Atherosclerotic Cardiovascular Disease Risk Factors
Atherosclerotic Cardiovascular
Disease Risk Factors
Atherosclerotic Cardiovascular Disease Risk Factors
Case Study #1
This is a 51 year old white female, height 66”, weight 170 pounds. She is a retired Army officer. She has smoked approximately 2 packs of cigarettes per day for the last thirty- five years. Present activities include golf (walking with clubs) and tennis, each 2 days/week. No history of CAD in her family. The client complains of shortness of breath. Present BP is 158/90 mm Hg and RHR is 75 bpm. TC = 189 mg/dL, LDL = 139 mg/dL, HDL = 39 mg/dL, glucose = 100 mg/dL.
She drinks approximately 2 glasses daily
Veterans Specific Activity Questionnaire
(VSAQ)
Physical Activity Screening - Symptoms
Which of the following SxS do you have with exertion? (Table 2.2)
Chest discomfort or pain or in surrounding area
Type, when, severity
Shortness of breath (SOB)
Dizziness or syncope
Palpitations or tachycardia
Claudication (pain in legs)
Angina
Demand > Supply
Diagnosis (DX) – stress testing, angiography
Treatment –
Pharmacologic
Secondary Risk Reduction
Exercise – based on symptomology
AHA – Symptomology
“Chest discomfort. Most heart attacks involve discomfort in the center of the chest that lasts more than a few minutes, or that goes away and comes back. It can feel like uncomfortable pressure, squeezing, fullness or pain.
Discomfort in other areas of the upper body. Symptoms can include pain or discomfort in one or both arms, the back, neck, jaw or stomach.
Shortness of breath. May occurwithor without chest discomfort.
Other signs: These may include breaking out in a cold sweat, nausea or lightheadedness ”
Types of Angina and Associated Pathophysiology
Typical Angina – evoked by exertion, emotions, cold/heat exposure, meals, and sexual intercourse;
relieved by rest or nitroglycerin
Stable Angina – reproducible and predictable in onset
Atypical Angina – no relationship to exertion
Unstable Angina – new onset of typical angina, increasing in intensity or occurs at rest
Variant (Prinzmetal’s angina) -
Physical Activity Screening - Symptoms
Orthopnea or paroxysmal nocturnal dyspnea
Known heart murmur
Unusual fatigue or shortness of breath with usual activities
Physical Activity Screening - Symptoms
Major Signs/Symptoms Suggestive of Cardiovascular, Pulmonary, and
Metabolic Disease
Table 2-2
Risk Stratification
Table 2-1
Risk Stratification (cont.)
Figure 2-3
Need a physical exam and exercise test?
What type of test is recommended?
If an individual has a known cardiovascular disease, is it at all possible for them to be able to participate regularly in an exercise program to achieve and maintain a fit or at least a healthy lifestyle?
Exercise Testing and Testing Supervision
Recommendations Based Upon Risk
Category IMPORTANT!!
Secondary Risk Stratification
(for those who already have a medical diagnoses)
AACVPR
Low risk – stable, functional capacity > 6 METs, EF > 50%, symptoms may occur at high MET levels
Moderate – EF = 40 – 50%, reduced functional capacity (5-6 METs) with SxS
High – unstable, poor ventricular function, SxS below 5 METs
AHA
Class A, B, C, and D
Indications for Exercise Testing -
1.
Diagnosis
SxS
Exercise induced SxS
Angina
Old or new ECG abnormalities
2.
Prognosis
Use to predict mortality
3.
Exercise Capacity, Prescription
4.
Evaluate Rx Outcomes
(Froelicher. Handbook of Exercise Testing.1996
Contraindications to Exercise Testing
Do the risks of exercise testing out- weigh indications?
Absolute – under no circumstances*
should the test be performed
Relative – must weigh with indications for testing to determine outcome
Contraindications to Exercise Testing
Box 3-5
Contraindications to Exercise Testing
Box 3-5
Contraindications to Exercise Testing (cont.)
Risk/Benefit
Contraindications to Exercise Testing (cont.)
Patients with absolute contraindications should not perform exercise tests until such conditions are stabilized or adequately treated.
Patients with relative contraindications may be tested only after careful evaluation of the risk/benefit ratio.
Contraindications might not apply in certain specific clinical situations, such as soon after an acute
myocardial infarction, a revascularization procedure, or bypass surgery or to determine the need for, or benefit of, drug therapy.
Contraindications to Exercise Testing (cont.)
The exercise test may still provide useful information on:
exercise capacity,
dysrhythmias, and
hemodynamic responses to exercise.
In these conditions, additional evaluative techniques such as respiratory gas exchange analyses, echocardiography, or nuclear imaging can be added.
High degree Heart block High degree heart block
Normal
Contraindications for Exercise Testing Relative (Know!!) ...
Testing Facility (Emergency Procedures)
Need appropriate equipment (AHA)
Defibrillator?
Airway / oxygen
Drugs
Phone
Need appropriate staff
Physician
EMT/nurse
Exercise SpecialistSMor equivalent experience
Participant Instructions
Participants should refrain from ingesting food, alcohol, or caffeine or using tobacco products within 3 hours 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.
Participant Instructions (cont.)
If the evaluation is on an outpatient basis, participants should be made aware that the evaluation may be fatiguing and that they may wish to have someone accompany them to the assessment to drive them home afterward.
Participant Instructions (cont.)
If the 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 beta- blocking agents may be asked to taper their medication over a 2- to 4-day period to minimize hyperadrenergic withdrawal responses.
Participant Instructions (cont.)
If the test is for functional or exercise
prescription purposes, patients should continue
their medication regimen on their usualschedule so that the exercise responses will be consistent with responses expected during exercise training.
Participant Instructions (cont.)
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.
Participants should drink ample fluids over the 24- hour period preceding the test to ensure normal hydration before testing.
Case Study #1 – Should we do GXT and what type?
Jerry Attrik
67 yr old Caucasian male, recently retired
Not active
Wt = 217 lbs Ht = 68 in 125 cm waist circumference
Medications - Atenolol ( beta blocker), Ibuprofen
Heart Catheterization 2 years ago: results unknown
Family Hx – Father diagnosed with CAD Disease at Age 40
Resting BP – 128/88
Total Cholesterol 230 mg/dL – no other information on blood work is available
Reports being tense and overstressed often
Reports frequent episodes of chest tightness while mowing the lawn.
Case Study #2 – Does she need a physical exam and exercise test?
Moram Ovement
25 yr old Hispanic female
Wt = 157 lbs Ht = 62 in 30 percent body fat
She is going to join LA Fitness and go to their aerobics classes. She is a friend of yours and heard that you were an exercise science major. She wants advice on getting started and losing weight. She has never participated in a regular exercise program of any type. She currently smokes a few cigarettes a day. Her resting blood pressure is 138/86. Her blood parameters are all below risk level and she has no family history of CAD.
