ACSM[042-082]

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CHAPTER 3 Pre-Exercise Evaluations 53The determination of the maximal voluntary ventilation (MVV) should alsobe obtained during routine spirometric testing (9,13). This measurement can beused to estimate breathing reserve during maximal exercise. The MVV should bemeasured rather than estimated by multiplying the FEV 1 by a constant value, asis often done in practice (13).CONTRAINDICATIONS TO EXERCISE TESTINGFor certain individuals the risks of exercise testing outweigh the potential benefits.For these patients it is important to carefully assess risk versus benefit whendeciding whether the exercise test should be performed. Box 3.5 outlines bothabsolute and relative contraindications to exercise testing (7). Performing thepre-exercise test evaluation and the careful review of prior medical history, asdescribed earlier in this chapter, helps identify potential contraindications andincreases the safety of the exercise test. Patients with absolute contraindicationsshould not perform exercise tests until such conditions are stabilized or adequatelytreated. Patients with relative contraindications may be tested only aftercareful evaluation of the risk/benefit ratio. However, it should be emphasizedthat contraindications might not apply in certain specific clinical situations, suchas soon after acute myocardial infarction, revascularization procedure, or bypasssurgery or to determine the need for, or benefit of, drug therapy. Finally, conditionsexist that preclude reliable diagnostic ECG information from exercise testing(e.g., left bundle-branch block, digitalis therapy). The exercise test may stillprovide useful information on exercise capacity, dysrhythmias, and hemodynamicresponses to exercise. In these conditions, additional evaluative techniquessuch as respiratory gas exchange analyses, echocardiography or nuclearimaging can be added to the exercise test to improve sensitivity, specificity, anddiagnostic capabilities.Emergency departments may perform an exercise test on low-risk patientswho present with chest pain (i.e., within 4 to 8 hours) to rule out myocardialinfarction (4,7). Generally, these patients include those who are no longer symptomaticand who have unremarkable ECGs and no change in serial cardiacenzymes. However, exercise testing in this setting should be performed only aspart of a carefully constructed patient management protocol and only afterpatients have been screened for high-risk features or other indicators for hospitaladmission. Table 3.5 is a quick reference source for the time-course of changesin serum cardiac biomarkers for myocardial damage or necrosis (1).INFORMED CONSENTObtaining adequate informed consent from participants before exercise testingand participation in an exercise program is an important ethical and legal consideration.Although the content and extent of consent forms may vary, enoughinformation must be present in the informed-consent process to ensure that theparticipant knows and understands the purposes and risks associated with the
54 GUIDELINES FOR EXERCISE TESTING • www.acsm.orgBOX 3.5Contraindications to Exercise TestingAbsolute• A recent significant change in the resting ECG suggesting significantischemia, recent myocardial infarction (within 2 days), or other acutecardiac event• Unstable angina• Uncontrolled cardiac dysrhythmias causing symptoms orhemodynamic compromise• Symptomatic severe aortic stenosis• Uncontrolled symptomatic heart failure• Acute pulmonary embolus or pulmonary infarction• Acute myocarditis or pericarditis• Suspected or known dissecting aneurysm• Acute systemic infection, accompanied by fever, body aches, orswollen lymph glandsRelative a• Left main coronary stenosis• Moderate stenotic valvular heart disease• Electrolyte abnormalities (e.g., hypokalemia, hypomagnesemia)• Severe arterial hypertension (i.e., systolic BP of 200 mm Hg and/ora diastolic BP of 110 mm Hg) at rest• Tachydysrhythmia or bradydysrhythmia• Hypertrophic cardiomyopathy and other forms of outflow tractobstruction• Neuromuscular, musculoskeletal, or rheumatoid disorders that areexacerbated by exercise• High-degree atrioventricular block• Ventricular aneurysm• Uncontrolled metabolic disease (e.g., diabetes, thyrotoxicosis, ormyxedema)• Chronic infectious disease (e.g., mononucleosis, hepatitis, AIDS)• Mental or physical impairment leading to inability to exerciseadequatelya Relative contraindications can be superseded if benefits outweigh risks of exercise. In someinstances, these individuals can be exercised with caution and/or using low-level end points,especially if they are asymptomatic at rest.Modified from Gibbons RJ, Balady GJ, Bricker J, et al. ACC/AHA 2002 guideline update forexercise testing: a report of the American College of Cardiology/American Heart AssociationTask Force on Practice Guidelines (Committee on Exercise Testing) [Internet]. 2002. cited2007 June 15]. Available from: www.acc.org/clinical/guidelines/exercise/dirIndex.htm
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