An important role of the exercise professional is to ensure the safety of their clients and patients. The American College of Sports Medicine (ACSM) recommends that individuals interested in beginning or progressing in an exercise program undergo exercise preparticipation health screening. The purpose of this process is to identify individuals who may be at elevated risk for exercise-related sudden cardiac death (SCD) and/or acute myocardial infarction (AMI). Vigorous-intensity exercise has a small risk of an acute cardiovascular (CV) event; therefore, identifying susceptible individuals is important.
ACSM recently held a scientific round table to evaluate and refine the exercise preparticipation health screening procedures. Experts in the areas of risk assessment, preventive cardiology, general cardiology, public health, exercise physiology, and geriatrics as well as practitioners from the fields of medicine, clinical exercise physiology, and health fitness/prevention reviewed and discussed the scientific literature associated with the risk of exercise-related adverse CV events. The expert panel proposed new evidence-informed exercise preparticipation health screening recommendations procedures, which will be presented.
Although the goals of exercise preparticipation health screening remain the same, the new procedures represent a significant departure from the current edition of ACSM's Guidelines for Exercise Testing and Prescription (15). This article summarizes the changes in exercise preparticipation screening procedures, presents the rationale for the changes, and provides exercise professionals guidance in applying the new recommendations. The new ACSM recommendations are not a replacement for sound clinical judgment, and decisions about referral to a health care provider for medical clearance before the initiation of an exercise program should continue to be made on an individual basis (9).
WHY CHANGE THE EXISTING EXERCISE PREPARTICIPATION HEALTH SCREENING PROCESS?
Exercise is safe for most people. It is well known that the transient risks of SCD and AMI are substantially higher during acute vigorous physical exertion as compared with rest, especially in habitually sedentary people with known or occult (i.e., hidden) CV disease (CVD) who engage in unaccustomed strenuous physical exertion. However, the absolute risk of these events is extremely low. Both prospective and retrospective studies demonstrate the rarity of CV events during exercise (Table 1).
Cardiovascular disease risk factors do not predict adverse CV events. There is a high prevalence of CVD risk factors among adults, yet exercise-related SCD and AMI are extremely rare. For example, 65 million U.S. adults have hypertension and 71 million adults have high low-density lipoprotein cholesterol levels (3,12), yet only 600,000 people die from heart disease each year, and only a small fraction of those are caused by exercise-associated SCD and AMI (4). Therefore, using CVD risk factors to risk-identify those susceptible to exercise-associated SCD or AMI is unlikely to be effective in achieving its intended purpose. It is important to note that identifying and controlling CVD risk factors continue to be an important objective of overall CV and metabolic disease prevention and management. Therefore, exercise professionals are encouraged to complete a CVD risk factor assessment with their patients/clients even though it is no longer included in the exercise preparticipation health screening process as a determinant of medical clearance for exercise.
Current guidelines may be too conservative. The existing exercise preparticipation health screening may be overly conservative primarily because of the high prevalence of CVD risk factors. A recent study found that 95% of men and women older than 40 years would be advised to consult a physician before exercise based on the previous risk factor-based exercise preparticipation health screening process (19).
Prescreening may be a barrier to physical activity. Unnecessary referral to a health care provider to potentially identify underlying coronary artery disease may be a barrier to becoming physically active (15). Further diagnostic testing may lead to a high rate of false-positive exercise test responses in some populations, necessitating medical follow-up and additional noninvasive/invasive studies when they are not needed. Such studies can place unnecessary financial and other burdens on the individual and the health care system (6).
Warning signs and symptoms. Exercise-related CV events often are preceded by warning signs or symptoms (16).
There may be more effective ways to prevent exercise-related CV events. Exercise-related CV events more likely may be reduced by careful attention to the exercise prescription. The exercise prescription should incorporate a progressive transitional phase (i.e., 2 to 3 months) during which the duration and intensity of exercise are increased gradually and should include an appropriate warm-up and cool-down. Clients should be familiarized with the warning signs/symptoms of CVD and should be counseled to “start low and go slow”; that is, to avoid unaccustomed vigorous-to-near-maximal-intensity physical activity (Table 2).
WHAT IS NEW?
The current preparticipation health screening recommendations outlined in the ninth edition of ACSM's Guidelines for Exercise Testing and Prescription require the exercise professional to 1) complete a CVD risk factor profile; 2) determine if the client/patient has known CV, pulmonary, and/or metabolic diseases; and 3) identify major signs or symptoms suggestive of CV, pulmonary, and/or metabolic diseases. Using this information, the client/patient is classified as low, moderate, or high risk (13). Based on the risk classification and the intensity of the intended exercise training or exercise test, a decision is made concerning 1) the need for a medical examination, 2) the need for an exercise test, and 3) the need for a physician to be present during the exercise test (13).
The new preparticipation health screening process differs in that it does not include risk factor analysis or risk level classification and makes recommendations for physician clearance rather than specific recommendations for a medical examination or exercise test. Rather, it is based on 1) the individual’s current level of structured physical activity; 2) the presence of major signs or symptoms suggestive of CV, metabolic, or renal diseases; and 3) the desired exercise intensity (Figure 1). For a downloadable PDF, go to http://links.lww.com/FIT/A31.
The first part of the new screening process is to determine the level of participation in habitual exercise or a structured physical activity program. Several reasons have led to the decision of placing habitual exercise or structured physical activity program in a key role in the new exercise preparticipation screening recommendations. First, independent of any other risk factor, physically active individuals are at a lower risk for any cardiac event when compared with physically inactive individuals (7). Second, the relative risk of adverse cardiac events during exercise is inversely related to one's usual level of physical activity (5,11). Third, participation in regular physical activity reduces the risk of CVD-related events by half during a given 24-hour period (2,14). Lastly, an inverse relationship is apparent between the number of exercise sessions per week and the risk of experiencing CV-related events during these exercise sessions (5).
The recognition of known CV, metabolic, and renal diseases and the presence of major signs or symptoms suggestive of these diseases remains an important part of the preparticipation screening recommendations. However, individuals with pulmonary disease are no longer automatically required to receive medical clearance. Although CVD and pulmonary diseases share smoking as a common risk factor, the presence of pulmonary disease does not increase the risk of experiencing an adverse CVD event per se (15). In fact, the increased risk of an adverse CVD event is associated with the inactive and sedentary lifestyle of many individuals with pulmonary disease (8).
Finally, the recommendation for medical examination and/or diagnostic exercise test before the commencement of an exercise program was replaced with a recommendation for medical clearance (Figure 1). The term medical clearance was chosen to suggest that, after referral, the health care provider is in the best position to decide what the next step is in respect to the evaluation of a patient before approving the initiation of any exercise program (15). It is important to point out that although there are some substantial changes to the recommendations, the objectives of the process have remained the same as stated in the current guidelines (13):
- To identify those who should receive medical clearance before starting a new program or increasing the frequency, intensity, and/or volume of an existing exercise program.
- To identify those who present with CV, metabolic, and/or renal diseases and will benefit from participating in a medically supervised exercise program.
- To identify those with CV, metabolic, and/or renal diseases who must wait until their medical condition(s) have improved to proceed with an exercise program.
HOW TO USE THE UPDATED EXERCISE PREPARTICIPATION HEALTH SCREENING PROCESS?
As previously mentioned, the new exercise preparticipation health screening process is based on current levels of structured physical activity; the presence of major signs or symptoms suggestive of CV, metabolic, or renal diseases; and the desired exercise intensity. After the determination of the physical activity participation (defined as performing planned structured physical activity for at least 30 minutes at moderate intensity on at least 3 days/week for at least the last 3 months), a participant is placed into the “no” branch (left) or the “yes” branch (right) (Figure 1).
For individuals who are currently active:
- If asymptomatic without known CV, metabolic, or renal diseases, one may continue the exercise program and may progress gradually using published ACSM guidelines (13).
- If asymptomatic with known CV, metabolic, or renal diseases, one may continue the exercise program as long as one remains symptom free and as long as medical clearance was given within the last 12 months.
- If symptomatic with or without known CV, metabolic, or renal diseases, one should discontinue the exercise program and seek medical clearance.
For individuals who are currently inactive:
- If asymptomatic without known CV, metabolic, or renal diseases, one may engage in a light- to moderate-intensity exercise program and may progress gradually using published ACSM guidelines (13).
- If asymptomatic with known CV, metabolic, or renal diseases, one should discontinue the exercise program and seek medical clearance.
- If symptomatic with or without known CV, metabolic, or renal diseases, one should discontinue the exercise program and seek medical clearance.
To further simplify the exercise preparticipation screening process for the exercise professional, we have included a newly developed screening checklist (Figure 2). For a downloadable PDF, go to http://links.lww.com/FIT/A32. The checklist includes three easy-to-follow steps that may indicate to the exercise professional how to proceed with one's client (i.e., allow client to start an exercise program, participate in an exercise program, or refer client to a health care provider). To use the checklist, the exercise professional must determine if the client 1) has any signs or symptoms of CV, metabolic, or renal diseases; 2) is physically active; and 3) has a known CV, metabolic, or renal disease. The information gathered with the checklist will guide the exercise professional in making a decision about the need for medical clearance.
BRIDGING THE GAP
The benefits of engaging and maintaining habitual physical activity and exercise are well known. The updated ACSM preparticipation health screening recommendations are based on the available scientific evidence and are designed to remove barriers to exercise by eliminating the need for unnecessary health care provider referrals. This supports the public health message that physical activity is important for all individuals.
The authors thank Drs. Gary Liguori and Geoffrey Whitfield for their insightful comments and suggestions concerning the newly developed Figure 2.
1. Albert CM, Mittleman MA, Chae CU, Lee IM, Hennekens CH, Manson JE. Triggering of sudden death from cardiac causes by vigorous exertion. N Engl J Med
. 2000; 343(19): 1355–61.
2. Berlin JA, Colditz GA. A meta-analysis of physical activity in the prevention of coronary heart disease. Am J Epidemiol
. 1990; 132(4): 612–28.
3. Centers for Disease Control and Prevention (CDC). Adult participation in aerobic and muscle-strengthening physical activities — United States, 2011. MMWR Morb Mortal Wkly Rep
. 2013; 62(17): 326–30.
4. Centers for Disease Control and Prevention Web site [Internet]. Atlanta (GA): Centers for Disease Control and Prevention; [12/1/15]. Available from: http://www.cdc.gov/heartdisease/facts.htm
5. Dahabreh IJ, Paulus JK. Association of episodic physical and sexual activity with triggering of acute cardiac events: systematic review and meta-analysis. JAMA
. 2011; 305(12): 1225–33.
6. Franklin BA. Preventing exercise-related cardiovascular events: is a medical examination more urgent for physical activity or inactivity? Circulation
. 2014; 129(10): 1081–4.
7. Franklin BA, McCullough PA. Cardiorespiratory fitness: an independent and additive marker of risk stratification and health outcomes. Mayo Clin Proc
. 2009; 84(9): 776–9.
8. Hill K, Gardiner PA, Cavalheri V, Jenkins SC, Healy GN. Physical activity and sedentary behaviour: applying lessons to chronic obstructive pulmonary disease. Intern Med J
. 2015; 45(5): 474–82.
9. Kim JH, Malhotra R, Chiampas G, et al Cardiac arrest during long-distance running races. N Engl J Med
. 2012; 366(2): 130–40.
10. Malinow M, McGarry D, Kuehl K. Is exercise testing indicated for asymptomatic active people? J Cardiac Rehabil
. 1984; 4(9): 376–80.
11. Mittleman MA, Maclure M, Tofler GH, Sherwood JB, Goldberg RJ, Muller JE. Triggering of acute myocardial infarction by heavy physical exertion. Protection against triggering by regular exertion. Determinants of Myocardial Infarction Onset Study Investigators. N Engl J Med
. 1993; 329(23): 1677–83.
12. Nwankwo T, Yoon SS, Burt V, Gu Q. Hypertension among adults in the United States: National Health and Nutrition Examination Survey, 2011–2012. NCHS Data Brief
. 2013;(133): 1–8.
13. Pescatello LS.American College of Sports Medicine. ACSM's Guidelines for Exercise Testing and Prescription
. 9th ed. Philadelphia (PA): Wolters Kluwer/Lippincott Williams & Wilkins Health; 2014. xxiv, 456 p.
14. Powell KE, Thompson PD, Caspersen CJ, Kendrick JS. Physical activity and the incidence of coronary heart disease. Annu Rev Public Health
. 1987; 8: 253–87.
15. Riebe D, Franklin BA, Thompson PD, et al Updating ACSM's recommendations for exercise preparticipation health screening. Med Sci Sports Exerc
. 2015; 47(11): 2473–9.
16. Thompson PD, Franklin BA, Balady GJ, et al 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(17): 2358–68.
17. Thompson PD, Funk EJ, Carleton RA, Sturner WQ. Incidence of death during jogging in Rhode Island from 1975 through 1980. JAMA
. 1982; 247(18): 2535–8.
18. Whang W, Manson JE, Hu FB, et al Physical exertion, exercise, and sudden cardiac death in women. JAMA
. 2006; 295(12): 1399–403.
19. Whitfield GP, Pettee Gabriel KK, Rahbar MH, Kohl HW III. Application of the American Heart Association/American College of Sports Medicine Adult Preparticipation Screening Checklist to a nationally representative sample of US adults aged >=40 years from the National Health and Nutrition Examination Survey 2001 to 2004. Circulation
. 2014; 129(10): 1113–20.