Using screening results for risk stratification. With completion of the initial health appraisal and, if indicated, medical consultation and supervised exercise test, participants can be further classified for exercise training on the basis of individual characteristics detailed below. The following classifications have been modified using existing AHA (8) and ACSM (2) guidelines and are recommended (Table 5):
Class A: Apparently healthy. There is no evidence of increased cardiovascular risk for exercise. This classification includes 1) "apparently healthy" younger persons (Class A-1) and 2) irrespective of age, persons who are "apparently healthy" or at "increased risk" (Classes A-2 and A-3) and who have a normal diagnostic maximal exercise test. Submaximal exercise tests are sometimes performed at health/fitness facilities where permitted by law for nondiagnostic purposes, including physical fitness assessment, exercise prescription, and monitoring of progress (2). Such testing is also useful for educating participants about exercise and for motivating them. Nondiagnostic exercise testing should be conducted only for persons in Class A and only by appropriately qualified, well-trained personnel (see section on staffing below) who are knowledgeable about indications and contraindications for exercise testing, indications for test termination, and test interpretation. All health/fitness facilities, including those where exercise testing is performed, should have an emergency plan (see section on emergency policies and procedures below) to ensure that emergencies are handled safely, efficiently, and effectively. No restrictions other than provision of basic guidelines are required for exercise training. No special supervision is required during exercise training.
Class B: Presence of known, stable cardiovascular disease with low risk for vigorous exercise but slightly greater than for apparently healthy persons. This classification includes clinically stable persons with 1) coronary artery disease (myocardial infarction, coronary artery bypass surgery, percutaneous transluminal coronary angioplasty, angina pectoris, abnormal exercise test, or abnormal coronary angiogram); 2) valvular heart disease; 3) congenital heart disease (risk stratification for patients with congenital heart disease should be guided by the 26th Bethesda Conference recommendations (28)); 4) cardiomyopathy (includes stable patients with heart failure with characteristics as outlined below but not recent myocarditis or hypertrophic cardiomyopathy); and 5) exercise test abnormalities that do not meet the criteria outlined in Class C below. The clinical characteristics of such persons are 1) New York Heart Association (NYHA) Class I or II (Table 6); 2) exercise capacity >6 METs; 3) no evidence of heart failure; 4) free of ischemia or angina at rest or on the exercise test ≤ 6 METs; 5) appropriate rise in systolic blood pressure during exercise; 6) absence of nonsustained or sustained ventricular tachycardia; and 7) ability to satisfactorily self-monitor intensity of activity. For these persons, activity should be individualized with exercise prescription by qualified personnel. Medical supervision is recommended during prescription sessions and nonmedical supervision by appropriately qualified staff for other exercise sessions until the participant understands how to monitor his or her own activity. Subsequent exercise training may be performed without special supervision.
Class C: Those at moderate to high risk for cardiac complications during exercise and/or who are unable to self-regulate activity or understand the recommended activity level. This classification includes persons with 1) coronary artery disease with the clinical characteristics outlined below; 2) acquired valvular heart disease; 3) congenital heart disease (risk stratification for patients with congenital heart disease should be guided by the 26th Bethesda Conference recommendations (28)); 4) cardiomyopathy (includes stable patients with heart failure with characteristics as outlined below but not recent myocarditis or hypertrophic cardiomyopathy); 5) exercise test abnormalities not directly related to ischemia; 6) a previous episode of ventricular fibrillation or cardiac arrest that did not occur in the presence of an acute ischemic event or cardiac procedure; 7) complex ventricular arrhythmias that are uncontrolled at mild to moderate work intensity with medication; 8) threevessel or left main coronary artery disease; and 9) ejection fraction < 30%. One or more of the following clinical characteristics are also present: 1) two or more previous myocardial infarctions; 2) NYHA Class III or greater; 3) exercise capacity <6 METs; 4) ischemic horizontal or down-sloping ST depression ≥ 1 mm or angina at a workload ≤6 METs; 5) a fall in systolic blood pressure with exercise; 6) a medical problem that the physician believes may be potentially life-threatening; 7) a previous episode of primary cardiac arrest; and 8) ventricular tachycardia at a workload <6 METs. Physical activity should be individualized, and exercise should be prescribed by appropriately qualified medical personnel. Medical supervision, monitoring for adverse signs and symptoms, electrocardiographic monitoring of heart rate and rhythm, and blood pressure monitoring are recommended during exercise sessions until safety is established. Subsequent exercise training should be supervised by appropriately qualified personnel.
Class D: Unstable conditions with activity restriction. This classification includes those with 1) unstable ischemia; 2) heart failure that is not compensated; 3) uncontrolled arrhythmias; 4) severe and symptomatic aortic stenosis; 5) hypertrophic cardiomyopathy or cardiomyopathy from recent myocarditis; 6) severe pulmonary hypertension; or 7) other conditions that could be aggravated by exercise (for example, resting systolic blood pressure >200 mm Hg or resting diastolic blood pressure >110 mm Hg; active or suspected myocarditis or pericarditis; suspected or known dissecting aneurysm; thrombophlebitis and recent systemic or pulmonary embolus). In this population no physical activity is recommended for conditioning purposes. Risk stratification for patients with congenital heart disease should be guided by the 26th Bethesda Conference recommendations (28).
These classifications are presented as a means of beginning exercise with the lowest possible risk. They do not consider accompanying morbidities (for example, insulindependent diabetes mellitus, morbid obesity, severe pulmonary disease, complicated pregnancy, or debilitating neurological or orthopedic conditions) that may constitute a contraindication to exercise or necessitate closer supervision during exercise training.
Using screening results for exercise prescription. For individuals considered to be in Class A, exercise training intensity (Table 4) may be prescribed using the rating of perceived exertion alone and/or specific target heart rates. A suggested rating of perceived exertion for such persons is 12 - 16 (moderate to hard) on the Borg scale of 6-20 and/or an intensity level that corresponds to 50-90% of maximum heart rate or 45-85% of maximum oxygen uptake or heart rate reserve. Heart rate reserve is defined as maximum heart rate minus resting heart rate. For persons taking medications that affect heart rate (e.g., β-adrenergic blockers), these heart rate methods do not apply unless guided by an exercise tolerance test.
In the absence of atrial fibrillation, frequent atrial or ventricular ectopy, a fixed-rate pacemaker, or similar conditions, exercise intensity should be prescribed for persons with cardiovascular disease (Class B or C) using target heart rates and perceived exertion ratings in accordance with previously published guidelines (2,8). For these persons, target heart rates should be prescribed using data obtained during exercise testing performed while the participant is taking his or her usual cardioactive medications. In the absence of myocardial ischemia or other significant exercise test abnormalities, a target range of 50-90% of peak heart rate or 45-85% of peak measured oxygen uptake or heart rate reserve is recommended. This intensity level corresponds to 12-16 (moderate to hard) on the Borg scale. In the presence of myocardial ischemia (i.e., ischemic ST-segment depression >1 mm, chest discomfort believed to be angina pectoris, or other symptoms believed to be an anginal equivalent), significant arrhythmia, or other significant exercise test abnormalities (e.g., a fall in systolic blood pressure from baseline, systolic blood pressure >240 mm Hg, or diastolic blood pressure >110 mm Hg), the target training intensity is derived from the heart rate associated with the abnormality. If this occurs at a high level of exercise, the above target heart rate recommendations are applicable, provided that the upper limit of the range is at least 10 beats per minute (bpm) below the level at which the abnormality appears. Other-wise, the recommended upper limit of training heart rate is 10 bpm less than that associated with the abnormality.
Health/fitness facility personnel involved in management or delivery of exercise programs must meet academic and professional standards and have the required experience as established by the ACSM (2,19). Such personnel include the general manager/executive director, medical liaison, fitness director, and exercise leader. In general, health/fitness facility personnel should have the formal training and experience needed to ensure that clients are provided with safe, effective programs and services. The levels of education and experience needed to ensure effectiveness and safety vary with the health status of the client population. The kinds of personnel who should be employed at health/fitness faciliies serving various types of clients are summarized in Table 5.
The general manager/executive director is responsible for the overall management of the facility and should have competencies in business as well as design and delivery of exercise programs.
The medical liaison reviews medical emergency plans, witnesses and critiques medical emergency drills, and reviews medical incident reports. In level 2 and 3 facilities (Table 5), the medical liaison may be a licensed physician, a registered nurse trained in advanced cardiac life support, or an emergency medical technician. In level 4 and 5 facilities (Table 5), the medical liaison must be a licensed physician.
The fitness director manages the facility's exercise and activity programs and is responsible for program design and the training and supervision of staff. He or she must have a degree in exercise science, another health-related field, or equivalent experience, and knowledge of exercise physiology, exercise programming, and operation of exercise facilities. The fitness director must hold professional certification at an advanced level by a nationally recognized health/fitness organization. In level 3 facilities this certification should be comparable to ACSM health fitness instructor certification. In level 4 and 5 facilities the fitness director should be certified at a level that correlates with ACSM exercise specialist certification. The exercise specialist typically holds a master's degree in exercise science or a related field and has extensive experience in exercise testing and leadership in clinical populations. He or she must be trained in cardiopulmonary resuscitation (CPR) and should have at least 1 yr of supervisory experience in the fitness industry.
The exercise leader works directly with program participants and provides instruction and leadership in specific modes of exercise. He or she also helps program participants master the behavioral skills needed to adhere to exercise programs. In level 1, 2, and 3 facilities the exercise leader as a minimum must have a high school diploma or equivalent and entry-level or higher professional certification from a nationally recognized health/fitness organization (comparable to ACSM exercise leader certification). In level 4 facilities, the exercise leader should have education and experience corresponding to that required by ACSM health fitness instructor certification. In level 5 facilities, the exercise leader should be either an exercise specialist or a health fitness instructor directly supervised by an exercise specialist. In all cases the exercise leader must be trained in CPR and should have prior supervised internship or work experience in the health/fitness industry.
Some health/fitness facilities provide services in allied health fields such as nutrition, stress management, and physical therapy. Personnel providing such services should meet current accepted professional standards in those fields and should be certified as recommended by relevant professional organizations and licensed by or registered with the state as required by law.
Emergency Policies and Procedures
All health/fitness facilities must have written emergency policies and procedures that are reviewed and practiced regularly. Such plans will correspond to the type of facility and risk level of its membership outlined in Table 5. All fitness center staff who directly supervise program participants should be trained in basic life support. Health/fitness facilities must develop appropriate emergency response plans and must train their staff in appropriate procedures to provide during a life-threatening emergency. When an incident occurs, each staff member must perform the necessary emergency support steps in accordance with established procedures. It is important for everyone to know the emergency plan. Emergency drills should be practiced once every 3 months or more often with changes in staff; retraining and rehearsal are especially important. When new staff are hired, new team arrangements may be necessary. Because life-threatening cardiovascular emergencies are rare, constant vigilance by staff and familiarity with the plan and how to follow it are important.
It is essential to acknowledge that emergency equipment alone does not save lives. Equipment alone may offer a false sense of security if it is not backed up with appropriate staffing. The training and preparedness of an astute professional staff who can readily handle emergencies is paramount. This issue is particularly important if persons with certain medical conditions are recruited and encouraged to exercise in a specific health/fitness facility. Such a facility has the responsibility to offer appropriate coverage by personnel as outlined above and in Table 5. Acquisition of equipment for evaluation and resuscitation will depend on the risk level of participants, personnel, and medical coverage. All facilities must have a telephone that is readily accessible and available when emergency assistance is needed. It would be useful for all supervised facilities to have a sphygmomanometer and stethoscope readily available. Level 4 and 5 facilities that recruit members with known cardiovascular disease must have such equipment available, and level 5 (supervised cardiac rehabilitation) facilities should be fully equipped according to the recommendations of the AHA (21) and the American Association of Cardiovascular and Pulmonary Rehabilitation (1). Such equipment includes a defibrillator, oxygen, and fully stocked crash cart. Delineation of specific equipment standards in such facilities is beyond the scope of these guidelines; such information is detailed in the documents above (1,21). Appropriately trained staff who are medically and legally empowered must be available to operate such devices during a facility's operational hours.
The emergency plan must address transportation of victims to a hospital emergency room and must include telephone access to 911 or the local emergency unit access system. Health/fitness facility personnel should be familiar with emergency transport teams in the area so that access and location of the center are clearly identified. Staff should greet the emergency response team at the entrance of the facility so that they can be promptly guided to the site of the emergency. A staff member should remain with the victim at all times. Prompt emergency transport is optimized by free and ready access to the victim within the health/fitness facility and assistance by designated staff.
General Considerations in Selecting a Health/Fitness Facility
In selecting a health/fitness facility, an individual should first consider his or her health status. Persons with a history of cardiovascular disease should seek facilities that provide or require a thorough medical evaluation of prospective members/users. Personnel should include nurses, exercise specialists, health/fitness instructors, and/or exercise leaders licensed or certified by the appropriate agencies, organizations, or authorities. They should be trained to recommend and supervise exercise in patients with cardiovascular and other chronic diseases. Persons at high risk for development of cardiovascular disease should seek facilities that require appropriate medical evaluation of clients and employ exercise leaders who are certified as competent to design and deliver exercise programs for high-risk persons. Table 5 summarizes personnel and safety recommendations for health/fitness facilities (levels 1 through 5) serving clients in various health categories (Classes A through C).
Persons seeking health/fitness facilities should select one that meets professional and industry standards. Facilities should be clean, well-maintained, and spacious enough to ensure the comfort and safety of program participants. Indoor facilities should be climate controlled, and changing rooms and showers should be provided. Flooring in areas where exercise is to be carried out should be designed to minimize risk of injury. Exercise equipment should be well-maintained. The variety, amount, and availability of exercise equipment should match individual needs and preferences, including time of day and preferred mode of exercise. For example, if aerobic dance is the preferred mode of exercise, individuals should seek a fitness center that offers this program at a convenient time and that provides an exercise leader who is competent in this activity and able to teach men and women of various age and fitness levels.
The programs and services of a health/fitness center should optimize participation. The location of the center should minimize time spent traveling to it. The social environment should be attractive and the staff competent in helping members/users master the behavioral skills needed to adopt and maintain a physically active lifestyle.
Summary of Key Points
* Physical inactivity is a risk factor for cardiovascular disease; it is very prevalent and an important health issue.
* Regular exercise reduces subsequent cardiovascular morbidity and mortality (7,17,18).
* Efforts to promote physical activity will impact everyone, including persons with cardiovascular disease.
* The incidence of a cardiovascular event during exercise among patients with cardiac disease is greater than that among otherwise healthy persons (8).
* Overall, in the general population the absolute incidence of death during exercise is relatively low (8).
* All facilities offering exercise equipment or services should conduct a cardiovascular screening of all new members and/or prospective users. Preparticipation screening should identify persons at high risk, and public health efforts should focus on increasing the use of screening. In view of the potential legal risk assumed by operators of fitness facilities, it is recommended that those facilities providing staff supervision document the results of screening.
* When a medical evaluation/recommendation is advised or required, written and active communication by facility staff with the individual's personal physician (or healthcare provider) is strongly recommended.
* Health appraisal questionnaires should be used before exercise testing and/or training to initially classify participants by risk for triage and preliminary decision making. After the initial health appraisal and, if indicated, medical consultation and supervised exercise test, participants can be further classified for exercise training on the basis of individual characteristics.
* Every effort should be made to educate participants about the importance of obtaining a preparticipation health appraisal and, if indicated, a medical evaluation/recommendation. The potential risks incurred without obtaining an appraisal and/or evaluation should also be emphasized.
* The AHA, the IHRSA, and the ACSM recommend that all health/fitness facilities have written emergency policies and procedures that are reviewed and practiced regularly (16,19). It is essential to acknowledge that emergency equipment alone does not save lives: training and preparedness by astute professional staff who can readily handle emergencies is paramount.
* Whatever their health status, persons seeking a health/fitness facility should choose one that provides equipment, programs, staff, services, and membership contracts appropriate for their needs and that meets accepted professional and industry standards.
1. American Association of Cardiovascular, and Pulmonary Rehabilitation. Guidelines for Cardiac Rehabilitation Programs,
2nd Ed. Champaign, IL: Human Kinetics Publishers, 1995.
2. American College of Sports Medicine. Guidelines for Exercise Testing and Prescription,
5th Ed., W. L. Kenney (Ed.). Baltimore: Williams & Wilkins; 1995:269-287.
3. American Heart Association. Heart and Stroke Facts: 1997 Statistical Supplement.
Dallas: AHA, 1996.
4. Anderson, K. M., P. W. Wilson, P. M. Odell, and W. B. Kannel. An updated coronary risk profile: a statement for health professionals. Circulation
5. Borg, G. A. Psychophysical basis of perceived exertion. Med. Sci. Sports Exerc.
6. Fletcher, G. How to implement physical activity in primary and secondary prevention: a statement for healthcare professionals from the American Heart Association. Circulation
7. Fletcher, G. F., G. J. Balady, S. N. Blair, et al. Statement on exercise: benefits and recommendations for physical activity programs for all Americans. Circulation
8. Fletcher, G. F., G. J. Balady, V. F. Froelicher, L. H. Hartley, W. L. Haskell, and M. L. Pollock. Exercise standards: a statement from the American Heart Association. Circulation
9. Gibbons, R. J., G. J. Balady, J. W. Beasley, et al. ACC/AHA guidelines for exercise testing: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J. Am. Coll. Cardiol.
10. Healthy People 2000: National Health Promotion and Disease Prevention Objectives. U.S. Dept. of Health and Human Services/Public Health Service. Publication no. (PHS) 91-50213.
11. How to Choose a Health Club.
Milwaukee, WI: Wisconsin Affiliate, American Heart Association, 1989.
12. Maron, B. J., P. D. Thompson, J. C. Puffer, et al. Cardiovascular preparticipation screening of competitive athletes: a statement for health professionals from the American Heart Association. Circulation
13. Maron, B. J., J. Shirani, L. C. Poliac, R. Mathenge, W. C. Roberts, and F. O. Mueller. Sudden death in young competitive athletes: clinical, demographic, and pathological profiles. J. A. M. A.
14. McInnis, K. J., S. Hayakawa, and G. J. Balady. Cardiovascular screening and emergency procedures at health clubs and fitness centers. Am. J. Cardiol.
15. Mittleman, M. A., M. Maclure, G. H. Tofler, J. B. Sherwood, R. J. Goldberg, and J. E. Muller. Triggering of acute myocardial infarction by heavy physical exertion: protection against triggering by regular exertion. N. Engl. J. Med.
16. 1997 IHRSA/American Sports Data Health Club Trend Report.
Hartsdale, NY: American Sports Data, 1997.
17. Paffenbarger, R. S., R. T. Hyde, A. L. Wing, and C. C. Hsieh. Physical activity, all-cause mortality, and longevity of college alumni. N. Engl. J. Med.
18. Pate, R. R., M. Pratt, S. N. Blair, et al. Physical activity and public health: a recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. J. A. M. A.
19. Peterson, J. A., and S. J. Tharrett, Eds. American College of Sports Medicine Health/Fitness Facility Standards and Guidelines,
2nd Ed. Champaign, IL: Human Kinetics Publishers, 1997.
20. Physical Activity and Health: A Report of the Surgeon General.
Atlanta: U.S. Department of Health and Human Services, Centersfor Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, 1996.
21. Pina, I. L., G. J. Balady, P. Hanson, A. J. Labovitz, D. W. Madonna, and J. Myers. Guidelines for clinical exercise testing laboratories: a statement for healthcare professionals from the American Heart Association. Circulation
22. Shephard, R. J., S. Thomas, and I. Weller. The Canadian home fitness test: 1991 update. Sports Med.
23. Siscovick DS, Weiss NS, Fletcher RH, Lasky T. The incidence of primary cardiac arrest during vigorous exercise. N. Engl. J. Med.
24. Thomas, S., J. Reading, and R. J. Shephard. Revision of the Physical Activity Readiness Questionnaire (PAR-Q). Can. J. Sports Sci.
25. Thompson, P. D. The cardiovascular complications of vigorous physical activity. Arch. Intern. Med.
26. Thompson, P. D., E. J. Funk, R. A. Carleton, W. Q. Sturner. Incidence of death during jogging in Rhode Island from 1975 through 1980. J. A. M. A.
27. Tofler, G. H., J. E. Muller, P. H. Stone, et al. Modifiers of timing and possible triggers of acute myocardial infarction in the Thrombolysis in Myocardial Infarction Phase II (TIMI II) study group. J. Am. Coll. Cardiol.
28. 26th Bethesda Conference. Recommendations for determining eligibility for competition in athletes with cardiovascular abnormalities. J. Am. Coll. Cardiol.
29. Van Camp, S. P., C. M. Bloor, F. O. Mueller, R. C. Cantu, and H. G. Olson. Nontraumatic sports death in high school and college athletes. Med. Sci. Sports Exerc.
30. Van Camp, S. P., and R. A. Peterson. Cardiovascular complications of outpatient cardiac rehabilitation programs. J. A. M. A.
© Williams & Wilkins 1998. All Rights Reserved.
31. Willich, S. N., M. Lewis, H. Lowel, H. R. Arntz, F. Schubert, and R. Schroder. Physical exertion as a trigger of acute myocardial infarction. N. Engl. J. Med.