Chapter 3
Preexercise Evaluation
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Introduction
• Abbreviated versions of the preexercise evaluation
described within this chapter are appropriate for
low- and moderate-risk individuals wishing to
engage in light-to-moderate intensity exercise
within health/fitness settings.
• High-risk individuals whether in health/fitness or
clinical settings will require a more intensive
medical evaluation prior to initiating an exercise
program (see Chapter 2).
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Introduction (cont.)
• A comprehensive preexercise test evaluation in the
clinical setting generally includes
– a medical history,
– a physical examination, and
– laboratory tests.
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Introduction (cont.)
• A preexercise evaluation that includes a physical
examination, an exercise test, and/or laboratory tests may
be warranted for lower risk individuals whenever
– the health/fitness and clinical exercise professional has
concerns about an individual’s cardiovascular disease
(CVD) risk,
– 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 a medical evaluation.
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Medical History, Physical Examination, and
Laboratory Tests
Box 3.1 Components of the Medical History
• Medical diagnosis
• Previous physical
examination findings
• History of symptoms
• Recent illness,
hospitalization, new
medical diagnoses, or
surgical procedures
• Orthopedic problems
• Medication use including
supplements and drug
allergies
• Other habits including
caffeine, alcohol, tobacco,
or drug use
• Exercise history
• Work history
• Family history
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Box 3.2 Components of the Preparticipation SymptomLimited Exercise Test Physical Examination (7)
Appropriate components of the physical examination may include the
following:
• Body weight; in many instances determination of body mass index,
waist girth, and/or body composition (percent body fat) is desirable
• Apical pulse rate and rhythm
• Resting blood pressure: seated, supine, and standing
• Auscultation of the lungs with specific attention to uniformity of
breath sounds in all areas (absence of rales, wheezes, and other
breathing sounds)
• Palpation of the cardiac apical impulse and point of maximal impulse
• Auscultation of the heart with specific attention to murmurs, gallops,
clicks, and rubs
• Palpation and auscultation of carotid, abdominal, and femoral arteries
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Box 3.2 Components of the Preparticipation
Symptom-Limited Exercise Test Physical
Examination (7) (cont.)
• Evaluation of the abdomen for bowel sounds, masses, visceromegaly,
and tenderness
• Palpation and inspection of lower extremities for edema and presence
of arterial pulses
• Absence or presence of tendon xanthoma and skin xanthelasma
• Follow-up examination related to orthopedic or other medical
conditions that would limit exercise testing
• Tests of neurologic function including reflexes and cognition (as
indicated)
• Inspection of the skin, especially of the lower extremities in known
patients with diabetes mellitus
Adapted from (7).
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Box 3.3 Recommended Laboratory Tests by
Level of Risk and Clinical Assessment
INDIVIDUALS AT LOW-TO-MODERATE RISK
• Fasting serum total cholesterol, LDL cholesterol, HDL cholesterol, and
triglycerides
• Fasting plasma glucose, especially in individuals ≥45 yr and younger
individuals who are overweight (body mass index ≥25 kg · m−2) and have
one or more of the following risk factors for Type 2 diabetes mellitus: a
first-degree relative with diabetes, member of a high-risk ethnic
population (e.g., African American, Latino, Native American, Asian
American, Pacific Islander), delivered a baby weighing >9 lb (4.08 kg) or
history of gestational diabetes, hypertension (BP ≥140/90 mm Hg in
adults), HDL cholesterol <40 mg · dL−1 (<1.04 mmol · L−1) and/or
triglycerides ≥150 mg · dL−1 (≥1.69 mmol · L−1), previously identified
impaired glucose tolerance or impaired fasting glucose (fasting glucose
≥100 mg · dL−1; ≥5.55 mmol · L−1), habitual physical inactivity,
polycystic ovary disease, and history of vascular disease
• Thyroid function, as a screening evaluation especially if dyslipidemia is
present
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Box 3.3 Recommended Laboratory Tests by
Level of Risk and Clinical Assessment
INDIVIDUALS AT HIGH RISK
• Preceding tests plus pertinent previous cardiovascular laboratory tests
(e.g., resting 12-lead ECG, Holter monitoring, coronary angiography,
radionuclide or echocardiography studies, previous exercise tests)
• Carotid ultrasound and other peripheral vascular studies
• Consider measures of lipoprotein(a), high sensitivity C-reactive protein,
LDL particle size and number, and HDL subspecies (especially in young
individuals with a strong family history of premature CVD and in those
individuals without traditional CVD risk factors)
• Chest radiograph, if heart failure is present or suspected
• Comprehensive blood chemistry panel and complete blood count as
indicated by history and physical examination (see Table 3.4)
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Box 3.3 Recommended Laboratory Tests by
Level of Risk and Clinical Assessment
PATIENTS WITH PULMONARY DISEASE
• Chest radiograph
• Pulmonary function tests (see Table 3.5)
• Carbon monoxide diffusing capacity
• Other specialized pulmonary studies (e.g., oximetry or blood gas
analysis)
BP, blood pressure; CVD, cardiovascular disease; ECG,
electrocardiogram; HDL, high-density lipoprotein cholesterol; LDL, lowdensity lipoprotein cholesterol.
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Blood Pressure
Box 3.4 Procedures for Assessment of Resting
Blood Pressure
1. Patients should be seated quietly for at least 5 min in a chair with back
support (rather than on an examination table) with their feet on the floor and
their arms supported at heart level. Patients should refrain from smoking
cigarettes or ingesting caffeine for at least 30 min preceding the
measurement.
2.
Measuring supine and standing values may be indicated under special
circumstances.
3.
Wrap cuff firmly around upper arm at heart level; align cuff with brachial
artery.
4.
The appropriate cuff size must be used to ensure accurate measurement.
The bladder within the cuff should encircle at least 80% of the upper arm.
Many adults require a large adult cuff.
5.
Place stethoscope chest piece below the antecubital space over the brachial
artery. Bell and diaphragm side of chest piece appear equally effective in
assessing BP (15).
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Blood Pressure
Box 3.4 Procedures for Assessment of Resting
Blood Pressure (cont.)
6.
Quickly inflate cuff pressure to 20 mm Hg above first Korotkoff sound.
7. Slowly release pressure at rate equal to 2–5 mm Hg · s−1.
8. SBP is the point at which the first of two or more Korotkoff sounds is heard
(phase 1), and DBP is the point before the disappearance of Korotkoff sounds
(phase 5).
9. At least two measurements should be made (minimum of 1 min apart) and the
average should be taken.
10.BP should be measured in both arms during the first examination. Higher
pressure should be used when there is consistent interarm difference.
11.Provide to patients, verbally and in writing, their specific BP numbers and BP
goals.
BP, blood pressure; DBP; diastolic blood pressure; SBP, systolic blood pressure.
Modified from (23). For additional, more detailed recommendations, see (21).
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Blood Pressure (cont.)
Lifestyle modification is the cornerstone of antihypertensive
therapy:
•Physical activity
•Weight reduction (if needed)
•DASH eating plan (i.e., a diet rich in fruits, vegetables, and
low-fat dairy products with a reduced content of saturated and
total fat), dietary sodium reduction (no more than 100 mmol or
2.4 g sodium · d−1)
•Moderation of alcohol consumption
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Blood Pressure (cont.)
• The Seventh Report of the Joint National Committee on
Prevention, Detection, Evaluation, and Treatment of High
Blood Pressure (JNC7) provides guidelines for hypertension
detection and management (see Table 3.1).
• According to JNC7, individuals with a systolic blood
pressure of 120–139 mm Hg and/or a diastolic BP of
80–89 mm Hg have prehypertension and require
health-promoting lifestyle modifications to prevent
the development of hypertension.
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Blood Pressure (cont.)
• JNC7 emphasizes the fact that most patients with
hypertension who require drug therapy in addition to lifestyle
modification require two or more antihypertensive
medications to achieve the goal BP (i.e., <140/90 mm Hg or
<130/80 mm Hg for patients with diabetes mellitus or
chronic kidney disease).
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Pulmonary Function
• Pulmonary function testing with spirometry is
recommended for all smokers >45 yr and in any
individual presenting with
– dyspnea (shortness of breath),
– chronic cough,
– wheezing, or
– excessive mucus production.
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Pulmonary Function (cont.)
• Spirometric testing is also valuable in identifying
patients with chronic disease (i.e., COPD and heart
failure) with diminished pulmonary function that
may benefit from an inspiratory muscle training
program.
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Pulmonary Function (cont.)
Commonly used spirometry measurements:
• Forced vital capacity (FVC)
• Forced expiratory volume in one second
(FEV1.0)
• FEV1.0/FVC ratio
• Peak expiratory flow (PEF)
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Pulmonary Function (cont.)
• The FEV1.0/FVC is diminished with
obstructive airway diseases (e.g., asthma,
chronic bronchitis, emphysema, chronic
obstructive pulmonary disease [COPD]).
• However, it remains normal with restrictive
disorders (e.g., kyphoscoliosis,
neuromuscular disease, pulmonary fibrosis,
other interstitial lung diseases).
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Contraindications to Exercise Testing
Assess Risk versus Benefit
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Box 3.5 Contraindications to Exercise Testing
ABSOLUTE
• A recent significant change in the resting electrocardiogram (ECG) suggesting
significant ischemia, recent myocardial infarction (within 2 d), or other acute
cardiac event
• Unstable angina
• Uncontrolled cardiac dysrhythmias causing symptoms or hemodynamic
compromise
• Symptomatic severe aortic stenosis
• Uncontrolled symptomatic heart failure
• Acute pulmonary embolus or pulmonary infarction
• Acute myocarditis or pericarditis
• Suspected or known dissecting aneurysm
• Acute systemic infection, accompanied by fever, body aches, or swollen lymph
glands
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Box 3.5 Contraindications to Exercise Testing (cont.)
RELATIVEa
• Left main coronary stenosis
• Moderate stenotic valvular heart disease
• Electrolyte abnormalities (e.g., hypokalemia or hypomagnesemia)
• Severe arterial hypertension (i.e., systolic blood pressure [SBP] of
>200 mm Hg and/or a diastolic BP [DBP] of >110 mm Hg) at rest
• Tachydysrhythmia or bradydysrhythmia
• Hypertrophic cardiomyopathy and other forms of outflow tract
obstruction
• Neuromotor, musculoskeletal, or rheumatoid disorders that are
exacerbated by exercise
• High-degree atrioventricular block
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Box 3.5 Contraindications to Exercise Testing (cont.)
RELATIVEa (cont.)
• Ventricular aneurysm
• Uncontrolled metabolic disease (e.g., diabetes, thyrotoxicosis, or
myxedema)
• Chronic infectious disease (e.g., HIV)
• Mental or physical impairment leading to inability to exercise
adequately
aRelative
contraindications can be superseded if benefits outweigh the
risks of exercise. In some instances, these individuals can be exercised
with caution and/or using low-level endpoints, especially if they are
asymptomatic at rest.
Modified from (11) cited 2007 June 15. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/12356646
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Contraindications to Exercise Testing (cont.)
• Patients with absolute contraindications should not
perform exercise tests until such conditions are
stabilized or adequately treated.
• Patients with relative contraindications may be tested
only after careful evaluation of the risk–benefit ratio.
• Contraindications might not apply in certain specific
clinical situations such as soon after an acute
myocardial infarction, a revascularization procedure, or
bypass surgery or to determine the need for or benefit
of drug therapy.
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Contraindications to Exercise Testing (cont.)
For conditions that preclude reliable diagnostic ECG information, the
exercise test may still provide useful information on:
• Exercise capacity
• Subjective symptomatology
• Pulmonary function
• Dysrhythmias
• The hemodynamic responses to exercise
Additional evaluative techniques such as ventilatory expired gas analysis,
echocardiography, or nuclear imaging can be added.
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Contraindications to Exercise Testing (cont.)
• Emergency departments may perform a symptomlimited exercise test on patients who present with chest
pain (i.e., 8–12 h after initial evaluation) and meet the
indications outlined in Table 3.6.
• This practice
– appears safe in appropriately screened patients,
– may improve diagnostic accuracy, and
– may reduce cost of care.
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Contraindications to Exercise Testing (cont.)
• Generally, these patients include those who are no
longer symptomatic and who have unremarkable ECGs
and no change in serial cardiac enzymes.
• Exercise testing in this setting should be performed
only as part of a carefully constructed patient
management protocol and only after patients have
been screened for high-risk features or other indicators
for hospital admission.
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25. Stein RA, Chaitman BR, Balady GJ, et al. Safety and utility of exercise testing in emergency room chest
pain centers: an advisory from the Committee on Exercise, Rehabilitation, and Prevention, Council on Clinical
Cardiology, American Heart Association. Circulation. 2000;102(12):1463–7.
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Informed Consent
• Obtaining adequate informed consent from
participants before exercise testing and
participation in an exercise program is an important
ethical and legal consideration.
• Although the content and extent of consent forms
may vary, enough information must be present in
the informed consent process to ensure that the
participant knows and understands the purposes
and risks associated with the test or exercise
program.
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Informed Consent (cont.)
• The consent form should be verbally explained and
include a statement indicating that the patient has
been given an opportunity to ask questions about
the procedure and has sufficient information to give
informed consent.
• Note specific questions from the participant on the
form along with the responses provided.
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Informed Consent (cont.)
• The consent form must indicate that the participant
is free to withdraw from the procedure at any time.
• If the participant is a minor, a legal guardian or
parent must sign the consent form.
• It is advisable to check with authoritative bodies
(e.g., hospital risk management, institutional review
boards, facility legal counsel) to determine what is
appropriate for an acceptable informed consent
process.
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Informed Consent (cont.)
• All reasonable efforts must be made to protect the privacy of
the patient’s health information (e.g., medical history, test
results) as described in the Health Insurance Portability and
Accountability Act (HIPAA) of 1996.
• No sample form should be adopted for a specific test or
program unless approved by local legal counsel and/or the
appropriate institutional review board.
• When the exercise test is for purposes other than diagnosis
or exercise prescription (i.e., for experimental purposes),
this should be indicated during the consent process and
applicable policies for the testing of human subjects must be
implemented.
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Informed Consent (cont.)
• Because most consent forms include a statement
that emergency procedures and equipment are
available, the program must ensure that available
personnel are appropriately trained and authorized
to carry out emergency procedures that use such
equipment.
• Written emergency policies and procedures should
be in place, and emergency drills should be
practiced at least once every 3 mo or more often
when there is a change in staff.
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Participant Instructions
• Participants should refrain from ingesting food, alcohol, or
caffeine or using tobacco products within 3 h of testing.
• Participants should be rested for the assessment, avoiding
significant exertion or exercise on the day of the
assessment.
• Clothing should permit freedom of movement and include
walking or running shoes. Women should bring a loose
fitting, short-sleeved blouse that buttons down the front and
should avoid restrictive undergarments.
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Participant Instructions (cont.)
• If the evaluation is on an outpatient basis,
participants should be made aware that the
exercise test may be fatiguing and that they may
wish to have someone accompany them to the
assessment to drive them home afterward.
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Participant Instructions (cont.)
• If the exercise test is for diagnostic purposes, it
may be helpful for patients to discontinue
prescribed cardiovascular medications, but only
with physician approval. Currently prescribed
antianginal agents alter the hemodynamic
response to exercise and significantly reduce the
sensitivity of ECG changes for ischemia. Patients
taking intermediate- or high-dose β-blocking agents
may be asked to taper their medication over a 2- to
4-d period to minimize hyperadrenergic withdrawal
responses (see Appendix A).
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Participant Instructions (cont.)
• If the test is for functional or exercise prescription
purposes, patients should continue their medication
regimen on their usual schedule so that the
exercise responses will be consistent with
responses expected during exercise training.
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Participant Instructions (cont.)
• Participants should bring a list of their medications
including dosage and frequency of administration to
the assessment and should report the last actual
dose taken. As an alternative, participants may
wish to bring their medications with them for the
exercise testing staff to record.
• Participants should drink ample fluids over the 24-h
period preceding the test to ensure normal
hydration before testing.
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The Bottom Line
The ACSM Exercise Testing Summary Statements are the
following:
•
The preexercise evaluation is vital to ensuring exercise
training can be safely initiated.
•
Regardless of whether or not an exercise test is indicated
prior to starting a physical activity program, identifying
known CVD risk factors (see Table 2.2) is important for
patient management.
•
Exercise testing information can be used to counsel an
individual regarding the risk for developing CVD,
tayloring the lifestyle intervention program (i.e.,
exercise, diet, and weight loss) to potentially ameliorate
CVD risk factors, and when appropriate, refer to the
appropriate health care professional for additional
assessment.
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The Bottom Line (cont.)
•
In those individuals who require exercise testing,
absolute and relative contraindications must be
considered before initiating the assessment (see Box
3.5).
•
Individuals undergoing an exercise test should receive
detailed instructions regarding the procedure and
complete an informed consent document.
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