ACSM[042-082]

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CHAPTER 2 Preparticipation Health Screening and Risk Stratification 23TABLE 2.1. ACSM RISK STRATIFICATION CATEGORIES FORATHEROSCLEROTIC CARDIOVASCULAR DISEASELow riskModerate riskHigh riskAsymptomatic men and women who have 1 CVD risk factorfrom Table 2.3Asymptomatic men and women who have 2 risk factorsfrom Table 2.3Individuals who have known cardiovascular, a pulmonary, b ormetabolic c disease or one or more signs and symptoms listedin Table 2.2ACSM, American College of Sports Medicine; CVD, cardiovascular disease.a Cardiac, peripheral vascular, or cerebrovascular disease.b Chronic obstructive pulmonary disease, asthma, interstitial lung disease, or cystic fibrosis.c Diabetes mellitus (type 1, type 2), thyroid disorders, renal, or liver disease.activity/exercise program may be pursued safely without the necessity formedical examination and clearance (1,20,22,23).Moderate risk: Individuals classified as moderate risk do not have signs/symptoms of or diagnosed cardiovascular, pulmonary, and/or metabolic disease,but have two or more (i.e., 2) CVD risk factors. The risk of an acute cardiovascularevent in this population is increased, although in most cases, individualsat moderate risk may safely engage in low- to moderate-intensity physicalactivities without the necessity for medical examination and clearance. However,it is advisable to have a medical examination and an exercise test beforeparticipation in vigorous intensity exercise (i.e., 60% V . O 2 R) (14,15).High risk: Individuals classified as high risk are those who have one or moresigns/symptoms of or diagnosed cardiovascular, pulmonary, and/or metabolicdisease. The risk of an acute cardiovascular event in this population is increasedto the degree that a thorough medical examination should take place and clearancegiven before initiating physical activity or exercise at any intensity.The exercise or health/fitness professional may evaluate the individual’s medical/healthhistory information and follow a logical sequence considering this riskstratificationprocess to determine into which appropriate risk category an individualshould be placed. Exercise or health/fitness professionals should have a thoroughknowledge of (a) the criteria for known cardiovascular, pulmonary, and metabolicdiseases; (b) the descriptions of signs and symptoms for these diseases; (c) the specificcriteria that determine the CVD risk-factor schemes; and (d) the criteria for eachrisk category. The flow chart in Figure 2.3 may be used to move sequentially throughthe process to determine the risk-category placement for each individual.UNDISCLOSED OR UNAVAILABLE CARDIOVASCULARDISEASE RISK-FACTOR INFORMATIONHealth/fitness and exercise professionals and clinicians are encouraged to adopta conservative approach to CVD risk-factor identification for the purposes ofrisk stratification, especially when (a) risk-factor information is missing and/or(b) the criteria for identifying the presence or absence of a specific risk factor
24 GUIDELINES FOR EXERCISE TESTING • www.acsm.orgReview Health/Medical Historyfor: Known Disease,Signs/Symptoms,CAD Risk FactorsKnown CV,Pulmonary, MetabolicDisease?Cardiovascular: Cardiac, peripheral vascular, orcerebrovascular diseasePulmonary: COPD, asthma, interstitial lung disease,or cystic fibrosisMetabolic: Diabetes mellitus (types 1 and 2), thyroiddisorders, renal or liver diseaseYesNoMajor Signs orSymptoms Suggestiveof CV, Pulmonary,Metabolic Disease?YesNoPain, discomfort in the chest, neck,jaw, arms, or other areas thatmay result from ischemiaShortness of breath at rest or withmild exertionDizziness or syncopeOrthopnea or paroxysmal nocturnaldyspneaAnkle edemaPalpitations or tachycardiaIntermittent claudicationKnown heart murmurUnusual fatigue or shortness of breathwith usual activitiesNumber of CAD RiskFactorsAgeFamily HistoryCurrent CigaretteSmokingSedentary LifestyleObesityHypertensionDyslipidemiaPre-diabetesHigh RiskModerateRiskLowRiskFIGURE 2.3. Logic model for risk stratification.cannot be determined or is not available. If the presence or absence of a specificrisk factor is not disclosed or is unavailable, the risk factor should be countedas a risk factor, except for prediabetes (8) (see Table 10.2 for diagnostic criteriafor prediabetes). Missing or unknown criteria for prediabetes should be countedas a risk factor in the presence of age (45 years), particularly for those with abody mass index 25 kgm 2 ,and for those who are younger, have a bodymass index 25 kgm 2 , and have additional risk factors for prediabetes (8).
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