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CHAPTER 2 Preparticipation Health Screening and Risk Stratification 25See Box 2.1 for case studies that involve undisclosed or unavailable CVD riskfactorinformation.KNOWN CARDIOVASCULAR, PULMONARY,AND METABOLIC DISEASEAn individual has known cardiovascular, pulmonary, and/or metabolic disease ifa physician has diagnosed one of the following conditions:• Cardiovascular disease (CVD): cardiac, peripheral artery (PAD), or cerebrovasculardisease• Pulmonary disease: chronic obstructive pulmonary disease (COPD), asthma,interstitial lung disease, or cystic fibrosis (5)• Metabolic disease: diabetes mellitus (type 1 or type 2), thyroid disorders, andrenal or liver diseaseMAJOR SIGNS/SYMPTOMS SUGGESTIVE OF CARDIOVASCULAR,PULMONARY, AND METABOLIC DISEASETable 2.2 presents a listing of major signs or symptoms suggestive of cardiovascular,pulmonary and/or metabolic disease in addition to information aidingthe clinician in the clarification and significance of each sign or symptom. Thepresence of most of these signs/symptoms may be identified using theAHA/ACSM Questionnaire (1) (Fig. 2.2); however, a few signs/symptoms (i.e.,orthopnea, ankle edema, and heart murmur) require a more thorough medicalhistory and/or examination. These signs/symptoms must be interpreted withinthe clinical context in which they appear because they are not necessarily specificfor cardiovascular, pulmonary, or metabolic disease.ATHEROSCLEROTIC CARDIOVASCULAR DISEASERISK FACTORSACSM risk stratification is based, in part, on the presence or absence of the CVDrisk factors listed in Table 2.3 (2,3,8,10,23). The health/medical history shouldbe reviewed to determine if the individual meets any of the criteria for positiverisk factors shown in Table 2.3. The number of positive risk factors is thensummed. Because of the cardioprotective effect of high-density lipoproteincholesterol (HDL-C), HDL-C is considered a negative risk factor. For individualshaving HDL-C 60 mgdL 1 (1.55 mmolL 1 ), one positive risk factor is subtractedfrom the sum of positive risk factors.The risk factors in Table 2.3 should not be viewed as an all-inclusive list of factorsassociated with elevated risk for CVD. Rather, Table 2.3 contains clinically relevantestablished CVD risk factor criteria that should be considered collectivelywhen making decisions about (a) the level of medical clearance, (b) the need forexercise testing before initiating participation, and (c) the level of supervisionfor both exercise testing and exercise program participation. The intended use forthe CVD risk factor list in Table 2.3 is to aid in the identification of occult coronary(text continues on page 30)
26 GUIDELINES FOR EXERCISE TESTING • www.acsm.orgTABLE 2.2. MAJOR SIGNS OR SYMPTOMS SUGGESTIVE OFCARDIOVASCULAR, PULMONARY, OR METABOLIC DISEASE aSIGN OR SYMPTOMPain, discomfort (or otheranginal equivalent) in thechest, neck, jaw, arms,or other areas that mayresult from ischemiaShortness of breath at restor with mild exertionDizziness or syncopeOrthopnea or paroxysmalnocturnal dyspneaCLARIFICATION/SIGNIFICANCEOne of the cardinal manifestations of cardiac disease, inparticular coronary artery diseaseKey features favoring an ischemic origin include:• Character: Constricting, squeezing, burning, “heaviness”or “heavy feeling”• Location: Substernal, across midthorax, anteriorly; in oneor both arms, shoulders; in neck, cheeks, teeth; inforearms, fingers in interscapular region• Provoking factors: Exercise or exertion, excitement, otherforms of stress, cold weather, occurrence after mealsKey features against an ischemic origin include:• Character: Dull ache; “knifelike,” sharp, stabbing; “jabs”aggravated by respiration• Location: In left submammary area; in left hemithorax• Provoking factors: After completion of exercise, provokedby a specific body motionDyspnea (defined as an abnormally uncomfortableawareness of breathing) is one of the principal symptomsof cardiac and pulmonary disease. It commonly occursduring strenuous exertion in healthy, well-trained personsand during moderate exertion in healthy, untrainedpersons. However, it should be regarded as abnormalwhen it occurs at a level of exertion that is not expectedto evoke this symptom in a given individual. Abnormalexertional dyspnea suggests the presence ofcardiopulmonary disorders, in particular left ventriculardysfunction or chronic obstructive pulmonary disease.Syncope (defined as a loss of consciousness) is mostcommonly caused by a reduced perfusion of the brain.Dizziness and, in particular, syncope during exercise mayresult from cardiac disorders that prevent the normal rise(or an actual fall) in cardiac output. Such cardiacdisorders are potentially life-threatening and includesevere coronary artery disease, hypertrophiccardiomyopathy, aortic stenosis, and malignantventricular dysrhythmias. Although dizziness or syncopeshortly after cessation of exercise should not be ignored,these symptoms may occur even in healthy persons as aresult of a reduction in venous return to the heart.Orthopnea refers to dyspnea occurring at rest in therecumbent position that is relieved promptly by sittingupright or standing. Paroxysmal nocturnal dyspnea refersto dyspnea, beginning usually 2–5 h after the onset ofsleep, which may be relieved by sitting on the side of thebed or getting out of bed. Both are symptoms of leftventricular dysfunction. Although nocturnal dyspnea mayoccur in persons with chronic obstructive pulmonary(continued)
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