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CHAPTER 2 Preparticipation Health Screening and Risk Stratification 27TABLE 2.2. MAJOR SIGNS OR SYMPTOMS SUGGESTIVE OFCARDIOVASCULAR, PULMONARY, OR METABOLIC DISEASE a(Continued)SIGN OR SYMPTOMAnkle edemaPalpitations or tachycardiaIntermittent claudicationKnown heart murmurUnusual fatigue orshortness of breath withusual activitiesCLARIFICATION/SIGNIFICANCEdisease, it differs in that it is usually relieved after theperson relieves himself or herself of secretions ratherthan specifically by sitting up.Bilateral ankle edema that is most evident at night is acharacteristic sign of heart failure or bilateral chronicvenous insufficiency. Unilateral edema of a limb oftenresults from venous thrombosis or lymphatic blockage inthe limb. Generalized edema (known as anasarca) occursin persons with the nephrotic syndrome, severe heartfailure, or hepatic cirrhosis.Palpitations (defined as an unpleasant awareness of theforceful or rapid beating of the heart) may be inducedby various disorders of cardiac rhythm. These includetachycardia, bradycardia of sudden onset, ectopic beats,compensatory pauses, and accentuated stroke volumeresulting from valvular regurgitation. Palpitations alsooften result from anxiety states and high cardiac output(or hyperkinetic) states, such as anemia, fever,thyrotoxicosis, arteriovenous fistula, and the so-calledidiopathic hyperkinetic heart syndrome.Intermittent claudication refers to the pain that occurs in amuscle with an inadequate blood supply (usually as aresult of atherosclerosis) that is stressed by exercise.The pain does not occur with standing or sitting, isreproducible from day to day, is more severe whenwalking upstairs or up a hill, and is often described as acramp, which disappears within 1–2 min after stoppingexercise. Coronary artery disease is more prevalent inpersons with intermittent claudication. Patients withdiabetes are at increased risk for this condition.Although some may be innocent, heart murmurs mayindicate valvular or other cardiovascular disease. Froman exercise safety standpoint, it is especially important toexclude hypertrophic cardiomyopathy and aortic stenosisas underlying causes because these are among the morecommon causes of exertion-related sudden cardiacdeath.Although there may be benign origins for these symptoms,they also may signal the onset of, or change in the statusof cardiovascular, pulmonary, or metabolic disease.a These signs or symptoms must be interpreted within the clinical context in which they appear because they are not allspecific for cardiovascular, pulmonary, or metabolic disease.Modified from Gordon SMBS. Health appraisal in the non-medical setting. In: Durstine JL, King AC, Painter PL. ACSM’sresource manual for guidelines for exercise testing and prescription. Philadelphia (PA): Lea & Febiger; 1993. p. 219–28.
28 GUIDELINES FOR EXERCISE TESTING • www.acsm.orgTABLE 2.3. ATHEROSCLEROTIC CARDIOVASCULAR DISEASE (CVD) RISKFACTOR THRESHOLDS FOR USE WITH ACSM RISK STRATIFICATIONPOSITIVE RISK FACTORSAgeFamily historyCigarette smokingSedentary lifestyleObesity aHypertensionDyslipidemiaPrediabetesDEFINING CRITERIAMen 45 yr; Women 55 yrMyocardial infarction, coronary revascularization, orsudden death before 55 yr of age in father or othermale first-degree relative, or before 65 yr of age inmother or other female first-degree relativeCurrent cigarette smoker or those who quit within theprevious 6 months or exposure to environmentaltobacco smokeNot participating in at least 30 min of moderateintensity (40%–60% V . O 2 R) physical activity on atleast three days of the week for at least threemonths (20,23)Body mass index 30 kgm 2 or waist girth 102 cm(40 inches) for men and 88 cm (35 inches) forwomen (2)Systolic blood pressure 140 mm Hg and/or diastolic90 mm Hg, confirmed by measurements on atleast two separate occasions, or on antihypertensivemedication (10)Low-density lipoprotein (LDL-C) cholesterol130 mgdL 1 (3.37 mmolL 1 ) or high-densitylipoprotein (HDL-C) cholesterol 40 mgdL 1 (1.04mmolL 1 ) or on lipid-lowering medication. If totalserum cholesterol is all that is available use 200mgdL 1 (5.18 mmolL 1 ) (3)Impaired fasting glucose (IFG) fasting plasmaglucose 100 mgdL 1 (5.50 mmolL 1 ) but 126mgdL 1 (6.93 mmolL 1 ) or impaired glucosetolerance (IGT) 2-hour values in oral glucosetolerance test (OGTT) 140 mgdL 1 (7.70 mmolL 1 ) but 200 mgdL 1 (11.00 mmolL 1 )confirmed by measurements on at least twoseparate occasions (8)NEGATIVE RISK FACTORDEFINING CRITERIAHigh-serum HDL cholesterol † 60 mgdL 1 (1.55 mmolL 1 )Note: It is common to sum risk factors in making clinical judgments. If HDL is high, subtract one risk factor from thesum of positive risk factors, because high HDL decreases CVD risk.a Professional opinions vary regarding the most appropriate markers and thresholds for obesity; therefore, allied healthprofessionals should use clinical judgment when evaluating this risk factor.artery disease. The scope of the list and the threshold for each risk factor are notinconsistent with other risk-factor lists established by other health organizationsthat are intended for use in predicting coronary events prospectively during longtermfollow up (24) . Furthermore, other risk factors, such as the inflammatorymarkers C-reactive protein and fibrinogen, also have been suggested as positiveand emerging CVD risk factors (11,13), but are not included in this list. Refer toCase Studies in Box 2.1 for further explanation.
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