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Testing & Prescription Exam 1
Terms in this set (86)
Any bodily movement produced by the contraction of skeletal muscles that results in a substantial increase in caloric requirements over resting energy expenditure
A type of physical activity consisting of planned, structured, and repetitive bodily movement done to improve and/or maintain one or more components of physical fitness
A set of attributes or characteristics that individuals have or achieve that relates to their ability to perform physical activity
The ability of the circulatory and respiratory system to supply oxygen during sustained physical activity.
The relative amounts of muscle, fat, bone, and other vital parts of the body
The ability of muscle to exert force
The ability of muscle to continue to perform without fatigue
The range of motion available at a joint.
Health-related physical fitness components
Skill-related physical fitness components
The ability to change the position of the body in space with speed and accuracy.
The ability to use the senses, such as sight and hearing, together with body parts in performing tasks smoothly and accurately.
The maintenance of equilibrium while stationary or moving
The ability or rate at which one can perform work
The time elapsed between stimulation and the beginning of the reaction to it
The ability to perform a movement within a short period of time.
Rest MET (metabolic equivalents)
-walking slowly (2)
-standing performing light work such as making bed, washing dishes, etc. (2.0-2.5)
-arts and crafts (1.5)
-playing most musical instruments (2.0-2.5)
-walking 3.0 mph (3.0)
-walking at brisk pace 4.0 mph (5.0)
-cleaning such as washing windows, cars, garage (3.0)
-sweeping floors or carpets (3.0-3.5)
-carrying/stacking wood, moving lawn with walk mower (5.5)
-badminton, shooting basketball, fast ballroom dancing (4.5)
-slow ballroom, sailing boat, wind surfing (3.0)
-fishing from riverbank, table tennis (4.0)
-tennis doubles (5.0)
-volleyball noncompetitive (3.0-4.0)
-(>= 6 METs)
-walking 4.5 mph (6.3)
-walking/hiking with no or light pack (7.0)
-hiking at steep grades (7.5-9.0)
-jogging 5 mph (8.0)
-jogging 6 mph (10.0)
-running 7 mph (11.5)
-shoveling snow (7.0)
-carrying something heavy (7.5)
-heavy farming (8.0)
-shoveling or digging ditches (8.5)
-basketball game (8.0)
-skiiing cross country (7.0-9.0)
-tennis singles (8.0)
-competitive volleyball (8.0)
Public Health Perspective for Current Recommendations
-A meta-analysis of 23 sex-specific cohorts of physical activity or fitness representing 1,325,004 individual-years of follow-up showed a dose-response relationship between physical activity or physical fitness and the risks of coronary artery disease and cardiovascular disease.
-Greater amounts of physical activity or increased physical fitness levels provide additional health benefits.
-Two important conclusions from the U.S. Surgeon General's Report that have impacted the development of these guidelines:
1). Important health benefits can be obtained by performing a moderate amount of physical activity on most, if not all, days of the week.
2).Additional health benefits result from greater amounts of physical activity. Individuals who maintain a regular program of physical activity that is longer in duration and/or is more vigorous in intensity are likely to derive greater benefit.
Public Health Perspective for Current Recommendations (cont.)
From the ACSM-AHA updated recommendation on physical activity and health:
"Since the 1995 recommendation, several large scale observational epidemiologic studies, enrolling thousands to tens of thousands of individuals, have clearly documented a dose-response relationship between physical activity and risk of cardiovascular disease and premature mortality in men and women, and in ethnically diverse participants."
The ACSM-AHA Primary Physical Activity Recommendations
-All healthy adults aged 18-65 yr should participate in moderate intensity, aerobic physical activity for a minimum of 30 min on 5 d · wk−1 or vigorous intensity, aerobic activity for a minimum of 20 min on 3 d · wk−1.
-Combinations of moderate and vigorous intensity exercise can be performed to meet this recommendation.
-Moderate intensity, aerobic activity can be accumulated to total the 30 min minimum by performing bouts each lasting ≥10 min.
-Every adult should perform activities that maintain or increase muscular strength and endurance for a minimum of 2 d · wk−1.
-Because of the dose-response relationship between physical activity and health, individuals who wish to further improve their fitness, reduce their risk for chronic diseases and disabilities, and/or prevent unhealthy weight gain may benefit by exceeding the minimum recommended amounts of physical activity
The Primary Physical Activity Recommendations from the 2008 Physical Activity Guidelines Committee Report
-All Americans should participate in an amount of energy expenditure equivalent to 150 min · wk−1 of moderate intensity, aerobic activity; 75 min · wk−1 of vigorous intensity, aerobic activity; or a combination of both that generates energy equivalency to either regimen for substantial health benefits.
-These guidelines further specify a dose-response relationship, indicating additional health benefits are obtained with 300 min · wk−1 or more of moderate intensity, aerobic activity; 150 min · wk−1 or more of vigorous intensity, aerobic activity; or an equivalent combination of moderate and vigorous intensity, aerobic activity.
-The 2008 federal physical activity guidelines also recommend breaking the total amount of physical activity into regular sessions during the week (e.g., 30 min on 5 d · wk−1 of moderate intensity, aerobic activity) in order to reduce the risk of musculoskeletal injuries.
Benefits of Regular Physical Activity and/or Exercise
-IMPROVEMENT IN CARDIOVASCULAR AND RESPIRATORY FUNCTION
•Increased maximal oxygen uptake resulting from both central and peripheral adaptations
•Decreased minute ventilation at a given absolute submaximal intensity
•Decreased myocardial oxygen cost for a given absolute submaximal intensity
•Decreased heart rate and blood pressure at a given submaximal intensity
•Increased capillary density in skeletal muscle
•Increased exercise threshold for the accumulation of lactate in the blood
•Increased exercise threshold for the onset of disease signs or symptoms (e.g., angina pectoris, ischemic ST-segment depression, claudication)
Benefits of Regular Physical Activity and/or Exercise
-REDUCTION IN CARDIOVASCULAR DISEASE RISK FACTORS
•Reduced resting systolic/diastolic pressure
•Increased serum high-density lipoprotein cholesterol and decreased serum triglycerides
• Total cholesterol - 1/3 triglyceride+HDL+LDL
• HDl above 140
•LDL lower 140
•Reduced total body fat, reduced intra-abdominal fat
•Reduced insulin needs, improved glucose tolerance
•Reduced blood platelet adhesiveness and aggregation
•Don't form major blood clots
Benefits of Regular Physical Activity and/or Exercise
-o Decreased morbitiy and mortality
•Primary prevention (i.e., interventions to prevent the initial occurrence)
•Right after birth
•Higher activity and/or fitness levels are associated with lower death rates from coronary artery disease
•Higher activity and/or fitness levels are associated with lower incidence rates for CVD, CAD, stroke, Type 2 diabetes mellitus, metabolic syndrome, osteoporotic fractures, cancer of the colon and breast, and gallbladder disease
•Secondary prevention (i.e., interventions after a cardiac event to prevent another)
•Higher life expectancy with aerobic and strength training
•Based on meta-analyses (i.e., pooled data across studies), cardiovascular and all-cause mortality are reduced in patients with post-myocardial infarction (MI) who participate in cardiac rehabilitation exercise training, especially as a component of multifactorial risk factor reduction
•Randomized controlled trials of cardiac rehabilitation exercise training involving patients with post-MI do not support a reduction in the rate of nonfatal reinfarction
Benefits of Regular Physical Activity and/or Exercise
-Decreased anxiety and depression
•Improved cognitive function
•Enhanced physical function and independent living in older individuals
•* Men are more likely to survive heart attack
•Enhanced feelings of well-being
•Enhanced performance of work, recreational, and sport activities
•Reduced risk of falls and injuries from falls in older individuals
•Prevention or mitigation of functional limitations in older adults
•Effective therapy for many chronic diseases in older adults
Sudden Cardiac Death among Young Individuals
•Absolute annual risk of exercise-related death among high school and college athletes:
• One per 133,000 men
• One per 769,000 women
•It should be noted that these rates, although low, include all sports-related nontraumatic deaths. Of the 136 total identifiable causes of death, 100 were caused by CVD.
Exercise-Related Cardiac Events in Adults
oAbsolute risk of sudden cardiac death during vigorous intensity, physical activity has been estimated at one per year for every 15,000-18,000 previously asymptomatic individuals.
oAlthough these rates are low, more recent available research has confirmed the increased rate of sudden cardiac death and acute MI among adults performing vigorous intensity exercise when compared to their younger counterparts.
oThe physically active or fit adult has about 30%-40% lower risk of developing CVD compared to those who are inactive.
Exercise Testing and the Risk of Cardiac Events
oThe risks of various cardiac events include acute MI, ventricular fibrillation, hospitalization, and death.
oThese data indicate that in a mixed population the risk of exercise testing is low, with approximately six cardiac events per 10,000 symptom-limited maximum tests.
Risks of Cardiac Events during
oIn one survey, there was one nonfatal complication per 34,673 h and one fatal cardiovascular complication per 116,402 h of cardiac rehabilitation.
oMore recent studies have found a lower rate, one cardiac arrest per 116,906 patient-hours, one MI per 219,970 patient-hours, one fatality per 752,365 patient-hours, and one major complication per 81,670 patient-hours.
oThe mortality rate appears to be six times higher when patients exercised in facilities without the ability to successfully manage cardiac arrest.
Prevention of Exercise-Related Cardiac Events
oHealth care professionals should know the pathologic conditions associated with exercise-related events so that physically active children and adults can be appropriately evaluated.
oPhysically active individuals should know the nature of cardiac prodromal symptoms and seek prompt medical care if such symptoms develop (see Table 2.1).
oHigh school and college athletes should undergo preparticipation screening by qualified professionals.
oAthletes with known cardiac conditions or a family history should be evaluated prior to competition using established guidelines.
oHealth care facilities should ensure that their staffs are trained in managing cardiac emergencies, have a specified plan, and have appropriate resuscitation equipment (see Appendix B).
oPhysically active individuals should modify their exercise program in response to variations in their exercise capacity, habitual activity level, and the environment.
Bottom Line of Cardiac Events
oA large body of scientific evidence supports the role of physical activity in delaying premature mortality and reducing the risks of many chronic diseases and health conditions. There is also clear evidence for a dose-response relationship between physical activity and health. Thus, any amount of physical activity should be encouraged.
oIdeally, an initial target should be 150 min · wk−1 of moderate intensity, aerobic activity; 75 min · wk−1 of vigorous intensity, aerobic activity; or an equivalent combination of moderate and vigorous intensity, aerobic activity. To minimize musculoskeletal injuries, physical activity bouts should be broken up during the week (e.g., 30 min of moderate intensity, aerobic activity on
5 d · wk−1).
oAdditional health benefits result from greater amounts of physical activity. Individuals who maintain a regular program of physical activity that is longer in duration and/or is more vigorous in intensity are likely to derive greater benefit than those who do lesser amounts.
oAlthough the risks associated with exercise transiently increase while exercising, especially exercising at vigorous intensity, the benefits of habitual physical activity substantially outweigh the risks. In addition, the transient increase in risk is of lesser magnitude among individuals who are regularly physically active compared with those who are inactive.
Risks of Exercise
•Most assessments involve performing exercise.
•Exercise may increase the risk of cardiovascular and musculoskeletal injuries for those with previous injuries or related diseases.
•Knowledge of health status and history is crucial for optimizing safety of the client
•The first step in the assessment process
-First impression of the program
• First contact with staff
• Assessment may cause anxiety
•Remain calm and professional
• Risks and discomforts
• Alternatives (if any)
• Responsibilities of the participant
•Encouragement of questions
•Explanation of data handling (confidentiality)
• Ability to withdraw consent and stop the assessment at any time
•Not just a form but a process.
•Documentation that attests to clear communication
•Read the entire form.
oBy the client or for the client
•Verbally review key elements.
•Reviewed on next slide
•Sign the form.
•Explanation of Procedures
•Be prepared to provide a brief description of each assessment to be performed and to answer questions.
oCardiovascular fitness: "This test is being performed to obtain an estimate of your cardiorespiratory fitness. The test will require you to exercise on a stationary cycle for 6-12 min. The intensity of the test will be limited to a level below your maximal exertion point. During the test, we will monitor your heart rate and blood pressure response to the submaximal exercise."
•Must precede the testing process
•Gathering a client's demographic and health-related information
• Health risk/medical history
• Determine risks for chronic disease and risks related to physical activity participation
• Question about factors identified on history
ACSM Preparticipation Health Screening Process
•"[The ACSM] supports the public health message that all people should adopt a physically active lifestyle."
•Similar to preassessment screening but geared toward
o Previously inactive individuals wishing to initiate regular exercise programs
o Performing moderate or irregular exercise but desire to increase the vigor and regularity of their exercise
•For exercise program, not assessment (which may include higher risk [maximal exertion])
Reasons for Screening
•To identify those with a medical contraindication (exclusion) to performing specific assessments
•To identify those who should receive a medical evaluation before performing specific assessments
•To identify those who should only perform some specific (vigorous) assessments administered by professionals with clinical experience
•To identify those with other health risk/medical concerns that may influence decision to perform assessments
Health History Questionnaire
•Assesses a client's
o Cardiovascular disease risk factors
o Past history and present status of any signs and symptoms suggestive of cardiovascular disease
o History of chronic diseases and illness
o History of surgeries and hospitalizations
o History of any musculoskeletal and joint injuries
o Past and present health behaviors and habits
o Current use of any medications
•Contraindications for Exercise
•Conditions for which exercise should not be performed
•Immediate risks outweigh potential benefit.
can be supervised if benefits outweigh risks of exercise
-in some cases, these individuals can be exercised with caution
exercise should not be performed
-Compared to previous editions of the Guidelines, the present version of Chapter 2:
• Reduces the emphasis on the need for medical evaluation in healthy, asymptomatic individuals.
• Uses the term risk classification to group individuals as low, moderate, or high risk based on the presence or absence of CVD risk factors, signs and symptoms, and/or known cardiovascular, pulmonary, renal, or metabolic disease.
-Emphasizes identifying those with known disease because they are at greatest risk for an exercise-related cardiac event.
-Adopts the AACVPR risk stratification scheme for individuals with known CVD.
-Supports the public health message that all individuals should adopt a physically active lifestyle.
Major Signs or Symptoms Suggestive of Cardiovascular, Pulmonary, or Metabolic Disease
- Pain; discomfort (or other anginal equivalent) in the chest, neck, jaw, arms, or other areas that may result from ischemia
- Shortness of breath at rest or with mild exertion
- Dizziness or syncope( passing out)
- Orthopnea(painful breathing) or paroxysmal nocturnal dyspnea(similar to sleep apnea)
- Ankle edema
- Palpitations or tachycardia(above 100 beats per min)
- Intermittent claudication(pain behind knee/calf;stop --> goes away)
- Known heart murmur
- Unusual fatigue or shortness of breath with usual activities
Risk Stratification for CV disease
- Potential participants should be screened for the presence, signs, symptoms, and/or risk factors of various cardiovascular, pulmonary, and metabolic diseases (see Table 2.1) as well as other health conditions (e.g., pregnancy, orthopedic injury) that require special attention in order to
• optimize safety during exercise testing and
• aid in the development of a safe and effective exercise prescription.
- The purposes of the preparticipation health screening include the following:
• Identification of individuals with medical contraindications that require exclusion from exercise programs until those conditions have been abated or controlled.
• Recognition of individuals with clinically significant disease(s) or conditions who should participate in a medically supervised exercise program.
- Detection of individuals at increased risk for disease because of age, symptoms, and/or risk factors who should undergo a medical evaluation and/or exercise testing before initiating an exercise program or increasing the frequency, intensity, or duration of their current program.
Participation Health Screening
- Preparticipation health screening may include:
• Self-guided methods such as the Physical Activity Readiness Questionnaire (PAR-Q) (see Figure 2.1) or the modified AHA/ACSM Health/Fitness Facility Preparticipation Screening Questionnaire (see Figure 2.2).
• CVD risk factor assessment and classification by qualified health/fitness, clinical exercise, or health care professionals.
• Medical evaluation including a physical examination and stress test by a qualified health care provider.
- Preparticipation health screening by self-reported medical history or health risk appraisal should be done for all individuals wishing to initiate a physical activity program.
- These self-guided methods can be easily accomplished by using such instruments as the PAR-Q (see Figure 2.1) or an adaptation of the AHA/ACSM Health/Fitness Facility Preparticipation Screening Questionnaire
Atherosclerotic Cardiovascular Disease Risk Factor Assessment
- Provides the health/fitness, clinical exercise, and health care professionals with important information for the development of a client or patient's Ex Rx.
- CVD risk factor assessment in combination with the determination of the presence of various cardiovascular, pulmonary, renal, and metabolic diseases is important when making decisions about
• the level of medical clearance,
• the need for exercise testing, and
• the level of supervision for exercise testing and exercise program participation
Atherosclerotic CV Disease Risk Factors and Defining Criteria
Age = Men >= 45 yr Women >= 55 year
Family History = Myocardial infarction, coronary revascularization, or sudden death, before 55 yr in father or other male first-degree relative or before 65 yr in mother or other female first-degree relative
Smoking = also includes nicotine patches, etc. or smokeless nicotine; quitting has to more than six months
Sedentary lifestyle = not participating in at least 30 min of moderate intensity physical activity on at least 3 days of work for at least 3 months
Obesity= good measurement is waist to hip ratio; 1 is obesity risk is high
Hypertension= can be systolic or diastolic, not both; on high bp medication; high bp must be taken on two separate occasions
Dislipidemia = abnormal lipids; 200 and above is a risk factor; want good cholesterol above 40; positive risk factors --> decreases heart disease; LDL 130 or above; HDL below 40; total 200 above or cholesterol meds
Prediabetes = fasting blood sugar done by lab has to be above 100 and below 125; above 125 is diabetes; takes oral glucose intolerance test after 2 hours; 14-0-199 = pre-diabetes; if don't know, count that as positive
Recommendations for following screening
- Use logic flow to determine risk level.
- Use classification to make further recommendations regarding
- Need for medical assessment prior to exercise
- Need for exercise assessment
- Level of training of staff
moderate intensity exercise; 40-60% VO2R; 3-<6 METs; an intensity that causes noticeable increases in HR and breathing
vigorous intensity exercise; >= 60% of VO2R; >=6 METs; an intensity that causes substantial increases in HR and breathing
asymptomatic <2 risk factors; asymptomatic men and women who have <2 CVD risk factor from Table 2.1
aymptomatic >= 2risk factors; aymptomatic men and women who have >=2 risk factors from Table 2.1
symptomatic, or known cardiovascular, pulmonary, renal, or metabolic disease; individuals who have any signs and symptoms listed in table 2.2
Recommendations for a Medical Examination prior to Initiating Physical Activity
• Individuals at moderate risk with two or more CVD risk factors (see Table 2.2 and Figure 2.3) should be encouraged to consult with their physician prior to initiating a vigorous intensity exercise program as part of good medical care and should progress gradually with their exercise program of any exercise intensity (see Figure 2.4). Although medical evaluation is taking place for the initiation of vigorous intensity exercise, the majority of these individuals can begin light-to-moderate intensity exercise programs such as walking without consulting a physician.
• Individuals at high risk with symptoms or diagnosed disease (see Table 2.1) should consult with their physician prior to initiating an exercise program (see Figure 2.4).
• CVD, cardiovascular disease.
Lowest Risk: American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) Risk Stratification Criteria for Patients with Cardiovascular Disease
• Characteristics of patients at lowest risk for exercise participation (all characteristics listed must be present for patients to remain at lowest risk)
• Absence of complex ventricular dysrhythmias during exercise testing and recovery
• Absence of angina or other significant symptoms (e.g., unusual shortness of breath, light-headedness, or dizziness, during exercise testing and recovery)
• Presence of normal hemodynamics during exercise testing and recovery (i.e., appropriate increases and decreases in heart rate and systolic blood pressure with increasing workloads and recovery)
• Functional capacity ≥7 metabolic equivalents (METs)
• Nonexercise Testing Findings
• Resting ejection fraction ≥50%
• Uncomplicated myocardial infarction or revascularization procedure
• Absence of complicated ventricular dysrhythmias at rest
• Absence of congestive heart failure
• Absence of signs or symptoms of postevent/postprocedure ischemia
• Absence of clinical depression
Moderate Risk: American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) Risk Stratification Criteria for Patients with Cardiovascular Disease
• Characteristics of patients at moderate risk for exercise participation (any one or combination of these findings places a patient at moderate risk)
• Presence of angina or other significant symptoms (e.g., unusual shortness of breath, light-headedness, or dizziness occurring only at high levels of exertion [≥7 METs])
• Mild to moderate level of silent ischemia during exercise testing or recovery (ST-segment depression <2 mm from baseline)
• Functional capacity <5 METs
• Nonexercise Testing Findings
• Rest ejection fraction 40% to 49%
Highest Risk: American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) Risk Stratification Criteria for Patients with Cardiovascular Disease
• Characteristics of patients at high risk for exercise participation (any one or combination of these findings places a patient at high risk)
• Presence of complex ventricular dysrhythmias during exercise testing or recovery
• Presence of angina or other significant symptoms (e.g., unusual shortness of breath, light-headedness, or dizziness at low levels of exertion [<5 METs] or during recovery)
• High level of silent ischemia (ST-segment depression ≥2 mm from baseline) during exercise testing or recovery
• Presence of abnormal hemodynamics with exercise testing (i.e., chronotropic incompetence or flat or decreasing systolic BP with increasing workloads) or recovery (i.e., severe postexercise hypotension)
• Nonexercise Testing Findings
• Rest ejection fraction <40%
• History of cardiac arrest or sudden death
• Complex dysrhythmias at rest
• Complicated myocardial infarction or revascularization procedure
• Presence of congestive heart failure
• Presence of signs or symptoms of postevent/postprocedure ischemia
• Presence of clinical depression
• Reprinted from (32), with permission from Elsevier.
• 32. Williams MA. Exercise testing in cardiac rehabilitation. Exercise prescription and beyond. Cardiol Clin. 2001;19(3):415-31.
Positive Risk Factors
• Family history
• Cigarette smoking
• Sedentary lifestyle
Negative Risk Factors
• High-density lipoprotein (HDL) cholesterol
• Subtracted from score to determine risk category
Signs and Symptoms of Cardiopulmonary Disease
- pain, discomfort in chest, neck, jaw, arms, or other areas that may result from ischemia
-shortness of breath at rest or with mild exertion
- dizziness or syncope
- orthopnea or paroxysmal nocturnal dyspnea
- ankle edema
- palpations or tachycardia
- intermittent claudication
- known heart murmur
- unusual fatigue or shortness of breath with usual activities
Understanding Medication Usage
o Obtain a list of all medications.
o Fitness professionals should have a basic understanding of medications classes, their side effects, and their effects on exercise.
o Fitness professionals should not instruct a client to stop taking or change the timing of his or her medication prior to any assessment
ACSM Pre participation Health Screening Recommendations
- All individuals wishing to initiate a physical activity program should be screened at minimum by a self-reported medical history or health risk appraisal questionnaire. The need and degree of follow-up is determined by the answers to these self-guided methods.
- Individuals at moderate risk with two or more CVD risk factors (see Table 2.2 and Figures 2.3 and 2.4) should be encouraged to consult with their physician prior to initiating a vigorous intensity, physical activity program. Although medical evaluation is taking place, the majority of these individuals can begin light-to-moderate intensity exercise programs such as walking without consulting their physician.
- Individuals at high risk with symptoms or diagnosed disease (see Table 2.1) should consult with their physician prior to initiating a physical activity program (see Figure 2.4).
- Routine exercise testing is recommended only for individuals at high risk (see Table 2.3 and Figures 2.3 and 2.4) including those with diagnosed CVD, symptoms suggestive of new or changing CVD, diabetes mellitus, and additional CVD risk factors, end-stage renal disease, and specified lung disease.
- 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 specially trained in clinical exercise testing, but whether or not a physician must be immediately available for exercise testing is dependent on a variety of considerations.
- These recommendations are made to reduce barriers to the adoption of a physically active lifestyle because (a) much of the risk associated with exercise can be mitigated by adopting a progressive exercise training regimen; and (b) there is an overall low risk of participation in physical activity programs (24).
A comprehensive preexercise test evaluation in the clinical setting generally includes
• a medical history,
• a physical examination, and
• laboratory tests.
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.
Components of 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
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
o Body weightàheight (stadiometer)
• Apical pulse rate and rhythm
o Apical pulse: stethoscope over apex of heart
o Listen to rhythm of lungs and palpate pulse and feel for arrythmias
• 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
• 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
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
• Around 20- look at cholesterol
• Look at thyroid - possible cholesterol problem
• Blood sugar- overweight, one or more of the following: first-degreee with diabetes, member of ethnic, delivering a baby weighing 9 lb., history of gestational diabetes, hypertension, HDL cholesterol <40 and /or triglycerides above 15o, impaired blood glucose efore, habitual physical inactivty, polycystic ovary disesase, history of vascular disease.
•Thyroid function, as a screening evaluation especially if dyslipidemia is present
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)
• CRP- means inflammatory markerà could be heart disese but also twisted ankle or something that becomes inflamed
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, low-density lipoprotein cholesterol.
encourage lifestyle mods
no antihypertensive drug indicated
drugs for compelling indications
Stage 1 hypertension
encourage lifestyle mods
antihypertensive drugs indicated
drugs for compelling indications; other antihypertensive drugs as needed
Stage 2 hypertension
SP >= 160
BP >= 100
encourage lifestyle mods
antihypertensive drugs indicated; two-drug combo for most
cornerstone of antihypertensive therapy
- physical activity
-weight reduction if needed
-DASH eating plan
-diet rich in fruits, veggies, and low-fat dairy products with reduced content of saturated and total fat; dietary sodium reduction ( no more than 100 mmil or 2.4 g sodium/ d-1
- moderation of alcohol consumption
all factors are elevated except HDL
-optimal LDL is below 100
conglomerate of body weight, insulin resistance, dyslipidemia, elevated blood pressure; at least three consistently; disorder in which multiple things going on in the endocrine system or metabolism
- 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.
- 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
Commonly used spirometry measurements
-Forced vital capacity (FVC)
- Forced expiratory volume in one second (FEV1.0)
- FEV1.0/FVC ratio
- Peak expiratory flow (PEF)
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).
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
Contraindications to Exercise Testing: relative
• 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
• 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.
• 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.
For conditions that preclude reliable diagnostic ECG information, the exercise test may still provide useful information on:
• Exercise capacity
• Subjective symptomatology
• Pulmonary function
• The hemodynamic responses to exercise
• Additional evaluative techniques such as ventilatory expired gas analysis, echocardiography, or nuclear imaging can be added.
Emergency departments may perform a symptom-limited 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.
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.
Prior to Exercise Testing
- Participants should refrain from ingesting food, alcohol, or caffeine or using tobacco products within 3 h of testing.
o Participants should be rested for the assessment, avoiding significant exertion or exercise on the day of the assessment.
o 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.
o 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.
o If the exercise test is for diagnostic purposes, it may be helpful for patients to discontinue prescribed cardiovascular medications, but only with physician approval.
o Currently prescribed antianginal agents alter the hemodynamic response to exercise and significantly reduce the sensitivity of ECG changes for ischemia.
o 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).
o 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.
o 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.
- Participants should drink ample fluids over the 24-h period preceding the test to ensure normal hydration before testing.
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