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ACSM’s New Preparticipation Health Screening Recommendations from ACSM’s Guidelines for Exercise Testing and Prescription, Ninth Edition

Thompson, Paul D. MD, FACSM1; Arena, Ross PhD, PT, FACSM2; Riebe, Deborah PhD, FACSM3; Pescatello, Linda S. PhD, FACSM, CPD4

doi: 10.1249/JSR.0b013e31829a68cf
Invited Commentary
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1Department of Cardiology, Hartford Hospital, Hartford, CT; 2University of Illinois Chicago, Chicago, IL; 3Department of Kinesiology, University of Rhode Island, Kingston, RI; and 4Human Performance Laboratory, Department of Kinesiology, Neag School of Education, University of Connecticut, Storrs, CT

Address for correspondence: Linda S. Pescatello, PhD, FACSM, CPD, Human Performance Laboratory, Department of Kinesiology, Neag School of Education, University of Connecticut, 2095 Hillside Road, U-1110, Storrs, CT 06269-1110; E-mail: Linda.Pescatello@uconn.edu.

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Introduction

Previously the American College of Sports Medicine (ACSM) preparticipation health screening recommendations were cardiovascular disease (CVD) risk assessment and stratification of all people, and a medical examination and symptom-limited exercise testing as part of the preparticipation health screening prior to initiating vigorous-intensity physical activity in individuals at increased risk for occult CVD (14). Individuals at increased risk in these recommendations were men ≥45 yr and women ≥55 yr; those with 2 or more major CVD risk factors; individuals with signs and symptoms of CVD; and those with known cardiac, pulmonary, or metabolic disease.

ACSM’s new preparticipation health screening recommendations are as follows:

  • Reduce the emphasis on the need for medical evaluation (i.e., medical examination and exercise testing) as part of the preparticipation health screening process prior to initiating a progressive exercise regimen in healthy, asymptomatic persons;
  • Use the term risk classification to group people as low, moderate, or high risk based upon the presence or absence of CVD risk factors, signs or symptoms, and/or known cardiovascular, pulmonary, renal, or metabolic disease;
  • Emphasize identifying those with known disease since they are at greatest risk for an exercise-related cardiac event (Table);
  • Adopt the American Association of Cardiovascular and Pulmonary Rehabilitation risk stratification scheme for people with known CVD because it considers over all patient prognosis and potential for rehabilitation (16); and
  • Support the public health message that all people should adopt a physically active lifestyle.
TABLE

TABLE

ACSM’s new preparticipation health screening recommendations continue to encourage atherosclerotic CVD risk factor assessment, since such measurements are an important part of the preparticipation health screening process and good medical care but do seek to simplify the preparticipation health screening process in order to remove unnecessary and unproven barriers to adopting a physically active lifestyle (11).

There are multiple considerations that have prompted these different points of emphasis. The risk of a cardiovascular event is increased during vigorous-intensity exercise relative to rest, but the absolute risk of a cardiac event is low in healthy individuals. Recommending a medical examination and/or stress test as part of the preparticipation health screening process for all people at moderate to high risk prior to initiating light- to moderate-intensity exercise program implies that being physically active confers greater risk than a sedentary lifestyle (3). Yet the cardiovascular health benefits of regular exercise far outweigh the risks of exercise for the general population (12,13).

There is also an increased appreciation that exercise testing is a poor predictor of acute CVD events such as heart attacks and sudden death in asymptomatic individuals probably because such testing detects flow-limiting coronary lesions, whereas sudden cardiac death and acute myocardial infarction are produced usually by the rapid progression of a previously nonobstructive lesion (13). Furthermore there is lack of consensus regarding the extent of the medical evaluation (i.e., medical examination and stress testing) needed as part of the preparticipation health screening process prior to initiating an exercise program even if it is of vigorous intensity (1,5,15). There is also evidence from decision analysis modeling that routine screening using exercise testing prior to initiating an exercise program is not warranted regardless of baseline individual risk (7). These considerations form the basis for the new ACSM preparticipation health screening recommendations that follows (10).

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Preparticipation Health Screening Recommendations

  • All people wanting to initiate a physical activity program should be screened at minimum by a self-reported medical history or health risk appraisal questionnaire such as the PAR-Q (4) or modified American Heart Association/ACSM Health/Fitness Facility PreparticipationScreening Questionnaire (2) for the presence of risk factors for various cardiovascular, pulmonary, renal, and metabolic diseases as well as other conditions (e.g., pregnancy and orthopedic injury) that require special attention when developing the exercise prescription (Ex Rx) (6,8,9).
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Recommendations for a Medical Examination Prior to Initiating Physical Activity

  • Individuals at moderate risk with two or more CVD risk factors (Figure) should be encouraged to consult with their physician prior to initiating a vigorous-intensity physical activity program. While medical evaluation is taking place, the majority of these people can begin without consulting a physician light- to moderate-intensity physical activity programs such as walking.
  • Individuals at high risk with symptoms or diagnosed disease (Table) should consult with their physician prior to initiating a physical activity program (Figure).
FIGURE

FIGURE

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Recommendations for Exercise Testing Prior to Initiating Physical Activity

  • Routine exercise testing before initiating a vigorous-intensity physical activity program is recommended only for individuals at high risk of exercise-related complications (Table and Figure).
  • Exercise testing is warranted also whenever the health/fitness and clinical exercise professional has concerns about an individual’s CVD risk or requires additional information to design an Ex Rx, or when the exercise participant has concerns about starting an exercise program of any intensity without such testing.
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Recommendations for Supervision of Exercise Testing

  • Exercise testing of individuals at high risk can be supervised by nonphysician health care professionals if the professional is specially trained in clinical exercise testing with a physician immediately available if needed.
  • Exercise testing of individuals at moderate risk can be supervised by nonphysician health care professionals if the professional is trained specifically in clinical exercise testing, but whether or not a physician must be immediately available for exercise testing is dependent on local policies and circumstances, the health status of the patients, and the training and experience of the laboratory staff.

In conclusion, the new ACSM preparticipation health screening recommendations are made to reduce barriers to the adoption of a physically active lifestyle because of the following: 1) Much of the risk associated with exercise can be mitigated by adopting a progressive exercise training regimen, and 2) there is an overall low risk of participation in physical activity programs (1).

The authors declare no conflicts of interest and do not have any financial disclosures.

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References

1. 2008 Physical Activity Guidelines for Americans [Internet]. Rockville (MD): Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services [cited 2010]. Available from: http://www.health.gov/paguidelines.
2. American College of Sports Medicine Position Stand and American Heart Association. Recommendations for cardiovascular screening, staffing, and emergency policies at health/fitness facilities. Med. Sci. Sports Exerc. 1998; 30: 1009–18.
3. Buchner DM. Physical activity to prevent or reverse disability in sedentary older adults. Am. J. Prev. Med. 2003; 25: 214–5.
4. Canada’s Physical Activity Guide to Healthy Active Living [Internet] [cited 2007 06/15]. Available from: http://www.phac-aspc.gc.ca/pau-uap/paguide/index.html.
5. Gibbons RJ, Balady GJ, Bricker JT, et al. American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Committee to Update the 1997 Exercise Testing Guidelines. ACC/AHA 2002 guideline update for exercise testing: summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). J. Am. Coll. Cardiol. 2002; 40: 1531–40.
6. Gordon SMBS. Health appraisal in the non-medical setting. In: Durstine JL, editor. ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription. 2nd ed. Philadelphia (PA): Williams & Wilkins; 1993. p. 219–28.
7. Lahav D, Leshno M, Brezis M. Is an exercise tolerance test indicated before beginning regular exercise? A decision analysis. J. Gen. Intern. Med. 2009; 24: 934–8.
8. Maron BJ, Araujo CG, Thompson PD, et al. World Heart Federation, International Federation of Sports Medicine, American Heart Association Committee on Exercise, Cardiac Rehabilitation, and Prevention. Recommendations for preparticipation screening and the assessment of cardiovascular disease in masters athletes: an advisory for healthcare professionals from the working groups of the World Heart Federation, the International Federation of Sports Medicine, and the American Heart Association Committee on Exercise, Cardiac Rehabilitation, and Prevention. Circulation. 2001; 103: 327–34.
9. Maron BJ, Thompson PD, Puffer JC, et al. Cardiovascular preparticipation screening of competitive athletes. A statement for health professionals from the Sudden Death Committee (clinical cardiology) and Congenital Cardiac Defects Committee (cardiovascular disease in the young), American Heart Association. Circulation. 1996; 94: 850–6.
10. Pescatello LS, Riebe D, Arena R, American College of Sports Medicine. ACSM’s Guidelines for Exercise Testing and Prescription. 9th ed. Baltimore (MD): Lippincott Williams & Wilkins; 2014.
11. Physical Activity Guidelines Advisory Committee Report, 2008 [Internet]. Washington (DC): U.S. Department of Health and Human Services [cited 2011 January 6]. Available from: http://www.health.gov/paguidelines/Report/pdf/CommitteeReport.pdf.
12. Thompson PD, Buchner D, Pina IL, et al. American Heart Association Council on Clinical Cardiology Subcommittee on Exercise, Rehabilitation, and Prevention, American Heart Association Council on Nutrition, Physical Activity, and Metabolism Subcommittee on Physical Activity. Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease: a statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity). Circulation. 2003; 107: 3109–16.
13. Thompson PD, Franklin BA, Balady GJ, et al. American Heart Association Council on Nutrition, Physical Activity, and Metabolism, American Heart Association Council on Clinical Cardiology, American College of Sports Medicine. Exercise and acute cardiovascular events placing the risks into perspective: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism and the Council on Clinical Cardiology. Circulation. 2007; 115: 2358–68.
14. Thompson WR, Gordon NF, Pescatello LS, American College of Sports Medicine. ACSM’s Guidelines for Exercise Testing and Prescription. 8th ed. Baltimore (MD): Lippincott Williams & Wilkins; 2010. p. 400.
15. U.S. Preventive Services Task Force. Screening for coronary heart disease: recommendation statement. Ann. Intern. Med. 2004; 140: 569–72.
16. Williams MA. Exercise testing in cardiac rehabilitation. Exercise prescription and beyond. Cardiol. Clin. 2001; 19: 415–31.
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