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CHAPTER 3 Pre-Exercise Evaluations 49powerful risk factor for CVD and that lowering of LDL cholesterol results in a strikingreduction in the incidence of CVD. Table 3.2 summarizes the ATP III classificationsof LDL, total, and high-density lipoprotein (HDL) cholesterol and triglycerides.According to ATP III, a low HDL cholesterol level is strongly and inverselyassociated with the risk for CVD. Clinical trials provide suggestive evidence thatraising HDL cholesterol levels reduces the risk for CVD. However, it now knownthat the serum HDL cholesterol level does not assess HDL’s functional propertiesand it remains uncertain whether raising HDL cholesterol levels per se, independentof other changes in lipid and/or nonlipid risk factors, always reduces therisk for CVD. In view of this, ATP III does not identify a specific HDL cholesterolgoal level to reach with therapy. Rather, nondrug and drug therapies that raiseHDL cholesterol that also are part of the management of other lipid and nonlipidrisk factors are encouraged by ATP III.There is growing evidence for a strong association between elevated triglyceridelevels and CVD risk. Recent studies suggest that some species of triglyceride-richlipoproteins, notably, cholesterol-enriched remnant lipoproteins, promote atherosclerosisand predispose to CVD. Because these remnant lipoproteins appear tohave atherogenic potential similar to that of LDL cholesterol, ATP III recommendsthat they be added to LDL cholesterol to become a secondary target of therapy forpersons with elevated triglycerides. To accomplish this, non-HDL cholesterol iscalculated by subtracting HDL cholesterol from the total cholesterol level.The metabolic syndrome is characterized by a constellation of metabolic riskfactors in one individual. Abdominal obesity, atherogenic dyslipidemia (i.e., elevatedtriglycerides, small LDL cholesterol particles, and reduced HDL cholesterol),elevated blood pressure, insulin resistance, prothrombotic state, andproinflammatory state generally are accepted as being characteristic of the metabolicsyndrome. The root causes of the metabolic syndrome are overweight andobesity, physical inactivity, and genetic factors. Because the metabolic syndromehas emerged as an important contributor to CVD, ATP III places emphasis on themetabolic syndrome as a risk enhancer.ATP III designates hypertension, cigarette smoking, diabetes, overweight andobesity, physical inactivity, and an atherogenic diet as modifiable nonlipid risk factors,whereas age, male sex, and family history of premature CVD are nonmodifiablenonlipid risk factors for CVD. Triglycerides, lipoprotein remnants, lipoprotein (a),small LDL particles, HDL subspecies, apolipoproteins B and A-1, and total cholesterol-to-HDLcholesterol ratio are designated by ATP III as emerging lipid risk factors.Thrombogenic and hemostatic factors, inflammatory markers (e.g., high-sensitivityC-reactive protein), impaired fasting glucose, and homocysteine are designatedby ATP III as emerging nonlipid risk factors. Regarding the latter, recent studies suggestthat homocysteine-lowering therapy does not result in a reduction in CVD risk.The guiding principle of ATP III and subsequent updates by the NationalHeart, Lung, and Blood Institute, American Heart Association, and American Collegeof Cardiology is that the intensity of LDL-lowering therapy should beadjusted to the individual’s absolute risk for CVD (8,10,15). The ATP III treatmentguidelines and subsequent updates by the National Heart, Lung, and Blood Institute,American Heart Association, and American College of Cardiology are summarizedin the ACSM Resource Manual.
50 GUIDELINES FOR EXERCISE TESTING • www.acsm.orgBLOOD PROFILE ANALYSESMultiple analyses of blood profiles are commonly evaluated in clinical exercise programs.Such profiles may provide useful information about an individual’s overallhealth status and ability to exercise and may help to explain certain ECG abnormalities.Because of varied methods of assaying blood samples, some caution isadvised when comparing blood chemistries from different laboratories. Table 3.3gives normal ranges for selected blood chemistries, derived from a variety ofsources. For many patients with CVD, medications for dyslipidemia and hypertensionare common. Many of these medications act in the liver to lower bloodTABLE 3.3. TYPICAL RANGES OF NORMAL VALUES FOR SELECTEDBLOOD VARIABLES IN ADULTS aVARIABLE MEN NEUTRAL WOMENHemoglobin (gdL 1 ) 13.5–17.5 11.5–15.5Hematocrit (%) 40–52 36–48Red cell count (10 12 /L) 4.5–6.5 3.9–5.6Mean cell hemoglobin 30–35 (gdL 1 )concentration (MCHC)White blood cell count4–11 (10 9 /L)Platelet count150–450 (10 9 /L)Fasting glucose b60–99 mgdL 1Blood urea nitrogen (BUN)4–24 mgdL 1Creatinine0.3–1.4 mgdL 1BUN/creatinine ratio 7–27Uric acid (mgdL 1 ) 4.0–8.9 2.3–7.8Sodium135–150 mEqdL 1Potassium3.5–5.5 mEqdL 1Chloride98–110 mEqdL 1Osmolality278–302 mOsm/kgCalcium8.5–10.5 mgdL 1Calcium, ion4.0–5.2 mgdL 1Phosphorus2.5–4.5 mgdL 1Protein, total6.0–8.5 gdL 1Albumin3.0–5.5 gdL 1Globulin2.0–4.0 gdL 1A/G ratio 1.0–2.2Iron, total (mcgdL 1 ) 40–190 35–180Liver Function TestsBilirubin1.5 mgdL 1SGOT (AST) 8–46 UL 1 7–34 UL 1SGPT (ALT) 7–46 UL 1 4–35 UL 1SGOT, serum glutamic-oxaloacetic transaminase; AST, aspartate transaminase (formerly SGOT); SGPT, serumglutamic-pyruvic transaminase; ALT, alanine transaminase (formerly SGPT).a Certain variables must be interpreted in relation to the normal range of the issuing laboratory.b Fasting blood glucose 100–125 mgdL 1 is considered impaired fasting glucose or prediabetes.NOTE: For a complete list of Système International (SI) conversion factors, please see http://jama.ama-assn.org/content/vol295/issue1/images/data/103/DC6/JAMA_auinst_si.dtl
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