Preparticipation Screening

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The link between living a physically active lifestyle and the accompanying reduction in several chronic diseases is well established. Physical activity is beneficial in the primary prevention of cardiovascular disease (CVD), stroke, diabetes, obesity, osteoporosis, anxiety, depression, and some cancers (34). Should an individual decide to start participating in a more active lifestyle, it would be prudent to take certain precautions to minimize the possible risks associated with initiating or increasing exercise. Contemporary preparticipation screening guidelines have focused primarily on risk classification (i.e., low, moderate, high) for individuals initiating exercise. This risk classification framework was based on the possible number of CVD risk factors or the presence of signs and symptoms and/or known cardiovascular, pulmonary, or metabolic disease. Thus, recommendations for a medical exam and exercise test were based on their risk classification and the proposed exercise intensity in an attempt to avoid exposing inactive individuals, with known or hidden CVD, to unaccustomed vigorous activity that may increase the risk of sudden cardiac death (SCD) and acute myocardial infarction (AMI).

Recent evidence suggests that this type of screening (39) may erroneously over-refer individuals to seek out medical clearance before exercise when, in fact, they do not require it and may inadvertently create a barrier for an individual to adopt a physically active lifestyle. Although the overall goal of exercise preparticipation screening has not changed (i.e., identify those at risk for an adverse event during exercise), a new paradigm has been created that will encourage physical activity, while minimizing barriers, still ensuring the safety of the exercise participant.

Preparticipation Health Screening

Exercise professionals should always incorporate some form of preparticipation screening or health appraisal prior to performing fitness testing or initiating an exercise program for an individual. The goals for preparticipation screening are (a) to identify who should receive medical clearance prior to initiating an exercise program or increasing the frequency, intensity, and/or volume of their current exercise program; (b) to identify those with clinically significant disease(s) to determine if they would benefit from participating in a medically supervised exercise program; and (c) to identify those with medical conditions who should be restricted from participating in an exercise program until their disease conditions are abated or better controlled. Based on these goals, the exercise professional will better understand and utilize the information from the preparticipation health screening algorithm (Fig. 3.1) by

Determining an individual’s current physical activity levels

Identifying signs and symptoms underlying CVD, metabolic disease, and renal disease (Table 3.1) in that person

Identifying individuals with diagnosed CVD and metabolic disease

Using an individual’s current level of exercise participation, disease history, signs and symptoms, and desired exercise program intensity to guide recommendations for preparticipation medical clearance.

FIGURE 3.1. The American College of Sports Medicine Preparticipation Screening Algorithm. (From Riebe D, Franklin BA, Thompson PD, et al. Updating ACSM’s recommendations for exercise preparticipation health screening. Med Sci Sports Exerc. 2015;47[8]:2473–9. Used with permission.)

Table 3.1

Major Signs and Symptoms Suggestive of Cardiovascular, Metabolic, and Renal Disease

Signs or Symptoms	Clarification/Significance
Pain; discomfort (or other anginal equivalent) in the chest, neck, jaw, arms, or other areas that may result from myocardial ischemia	One of the cardinal manifestations of cardiac disease, in particular, coronary artery disease
	Key features favoring an ischemic origin include the following: Character: constricting, squeezing, burning, “heaviness,” or “heavy feeling” Location: substernal, across midthorax, anteriorly; in one or both arms, shoulders; in neck, cheeks, teeth; in forearms, fingers in interscapular region Provoking factors: exercise or exertion, excitement, other forms of stress, cold weather, occurrence after meals
	Key features against an ischemic origin include the following: Character: dull ache; “knifelike,” sharp, stabbing; “jabs” aggravated by respiration Location: in left submammary area; in left hemithorax Provoking factors: after completion of exercise, provoked by a specific body motion
Shortness of breath at rest or with mild exertion	Dyspnea (defined as an abnormally uncomfortable awareness of breathing) is one of the principal symptoms of cardiac and pulmonary disease. It commonly occurs during strenuous exertion in healthy, well-trained individuals and during moderate exertion in healthy, untrained individuals. However, it should be regarded as abnormal when it occurs at a level of exertion that is not expected to evoke this symptom in a given individual. Abnormal exertional dyspnea suggests the presence of cardiopulmonary disorders, in particular, left ventricular dysfunction or chronic obstructive pulmonary disease.
Dizziness or syncope	Syncope (defined as a loss of consciousness) is most commonly caused by a reduced perfusion of the brain. Dizziness and, in particular, syncope during exercise may result from cardiac disorders that prevent the normal rise (or an actual fall) in cardiac output. Such cardiac disorders are potentially life-threatening and include severe coronary artery disease, hypertrophic cardiomyopathy, aortic stenosis, and malignant ventricular dysrhythmias. Although dizziness or syncope shortly after cessation of exercise should not be ignored, these symptoms may occur even in healthy individuals as a result of a reduction in venous return to the heart.
Orthopnea or paroxysmal nocturnal dyspnea	Orthopnea refers to dyspnea occurring at rest in the recumbent position that is relieved promptly by sitting upright or standing. Paroxysmal nocturnal dyspnea refers to dyspnea, beginning usually 2–5 h after the onset of sleep, which may be relieved by sitting on the side of the bed or getting out of bed. Both are symptoms of left ventricular dysfunction. Although nocturnal dyspnea may occur in individuals with chronic obstructive pulmonary disease, it differs in that it is usually relieved following a bowel movement rather than specifically by sitting up.
Ankle edema	Bilateral ankle edema that is most evident at night is a characteristic sign of heart failure or bilateral chronic venous insufficiency. Unilateral edema of a limb often results from venous thrombosis or lymphatic blockage in the limb. Generalized edema (known as anasarca) occurs in individuals with the nephrotic syndrome, severe heart failure, or hepatic cirrhosis.
Palpitations or tachycardia	Palpitations (defined as an unpleasant awareness of the forceful or rapid beating of the heart) may be induced by various disorders of cardiac rhythm. These include tachycardia, bradycardia of sudden onset, ectopic beats, compensatory pauses, and accentuated stroke volume resulting from valvular regurgitation. Palpitations also often result from anxiety states and high cardiac output (or hyperkinetic) states, such as anemia, fever, thyrotoxicosis, arteriovenous fistula, and the so-called idiopathic hyperkinetic heart syndrome.
Intermittent claudication	Intermittent claudication refers to the pain that occurs in the lower extremities with an inadequate blood supply (usually as a result of atherosclerosis) that is brought on by exercise. The pain does not occur with standing or sitting, is reproducible from day to day, is more severe when walking upstairs or up a hill, and is often described as a cramp, which disappears within 1–2 min after stopping exercise. Coronary artery disease is more prevalent in individuals with intermittent claudication. Patients with diabetes are at increased risk for this condition.
Known heart murmur	Although some may be innocent, heart murmurs may indicate valvular or other cardiovascular disease. From an exercise safety standpoint, it is especially important to exclude hypertrophic cardiomyopathy and aortic stenosis as underlying causes because these are among the more common causes of exertion-related sudden cardiac death.
Unusual fatigue or shortness of breath with usual activities	Although there may be benign origins for these symptoms, they also may signal the onset of or change in the status of cardiovascular disease or metabolic disease.

These signs or symptoms must be interpreted within the clinical context in which they appear because they are not all specific for cardiovascular disease.

Modified from 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): Lippincott Williams & Wilkins; 1993. p. 219–28.

It is important to note that an individual with pulmonary disease or a sign or symptom indicative of pulmonary disease will no longer be automatically referred for medical clearance. The presence of certain pulmonary diseases does not increase the risk of fatal or nonfatal cardiovascular complications during or immediately after exercise. It is believed that the risk of a cardiovascular complication in someone with pulmonary disease is not because of the disease but because of the person’s sedentary lifestyle (15).

Two types of preparticipation screening will be presented in this chapter. The first will be directed toward the exercise professional working with a general, nonclinical population and the second for those professionals working in a clinical or cardiopulmonary rehabilitation setting. For those exercise professionals who are working in a nonclinical setting, it is important to understand that there is a new process for performing preparticipation health screening. Previous screening methods relied heavily on CVD risk factor assessment and subsequent risk classification. The new American College of Sports Medicine (ACSM) algorithm is based on (a) an individual’s current level of physical activity; (b) the presence of signs or symptoms and/or known cardiovascular, metabolic, or pulmonary disease; and (c) the desired exercise intensity of the exercise prescription (ExR_x).

In the absence of a qualified exercise professional, the individual may use a self-screening method that will be explained later in this chapter. Also, if indicated during the screening process (see Fig. 3.1) that medical clearance should be sought from the appropriate health care provider, the manner of clearance should be determined by the health care provider using his or her clinical judgment. It is important to note that preparticipation health screening before initiating an exercise program should be distinguished from a periodic medical examination (34), which should be encouraged as part of routine health maintenance.

American College of Sports Medicine Preparticipation Screening Algorithm

The new ACSM preparticipation screening algorithm (29) is, in part, based on the knowledge that the relative risk for SCD and AMI in adults with underlying CVD is transiently increased during a bout of vigorous intensity exercise (24,32) but that the absolute risk during exercise is low in a healthy, asymptomatic individual (1,20,32,38). Evidence from the Physicians’ Health Study and Nurses’ Health Study suggest that SCD occurs every 1.5 million episodes of vigorous physical activity (1) and 36.5 million hours of moderate-to-vigorous physical activity in women (38). Exercise-related cardiovascular events are often preceded by warning signs and symptoms (32), and those events that ended in SCD were most often in people older than 35 years, where SCD could be attributed to underlying and often undiagnosed coronary artery disease (CAD) (21). Furthermore, physically inactive individuals are at a greater total risk for cardiac events compared with their active counterparts (11,34). Previous preparticipation screening included the assessment of CVD risk factors. There is insufficient evidence to suggest that the presence of one or more CVD risk factors, without underlying disease, confers any additional risk for an adverse event during exercise. With the high prevalence of CVD risk factors among adults (39) and the rarity of exercise-related SCD and AMI, the ability to predict cardiovascular events by assessing CVD risk factors becomes questionable, especially in otherwise healthy adults (32,33). Therefore, the new screening algorithm is based not on CVD risk factors but on whether or not the individual is sedentary or physically active.

The screening algorithm (see Fig. 3.1) starts by identifying whether or not the person presently participates in regular exercise. Individuals who are classified as currently exercising should have been physically active during the past 3 months for at least 30 minutes, on 3 or more days per week and exercising at a moderate intensity (40%–60% heart rate reserve [HRR] or 64%–76% maximal heart rate [HR_max]). The next level of classification is based on whether an individual has been told by a physician or other health care provider that he or she has a cardiovascular, metabolic, or renal disease or any signs or symptoms suggestive of cardiac, peripheral vascular, or cerebrovascular disease, Types 1 and 2 diabetes mellitus, or renal disease.

Once an individual’s disease status has been determined, the exercise professional should shift attention to an assessment of any signs and symptoms suggestive of these diseases (see Table 3.1). The presence of signs and symptoms should be done to better identify those who have an undiagnosed disease. This part of the process can often be difficult because of the vague or ambiguous responses from people. The exercise professional should take the time to have a one-on-one conversation in order to clarify any such responses by asking additional questions to help better differentiate whether a response is actually because of a pathological condition or because of a misunderstanding of the signs or symptoms.

The final step in using the preparticipation screening algorithm is to determine the desired exercise intensity (see Fig. 3.1) for the individuals’ ExR_x. It has been established that vigorous exercise is more likely to cause an acute cardiac event compared with light-to-moderate exercise in individuals (24,32). The exercise professional can utilize a health screening checklist (23) (Fig. 3.2) for guidance through this process. Once all the necessary information has been collected, individuals are grouped into one of six categories (left to right) in the screening algorithm (see Fig. 3.1).

1. Individuals who do not participate in regular exercise; have no known cardiovascular, metabolic, or renal disease; and have no signs or symptoms suggestive of disease can begin an exercise program at a light-to-moderate intensity without medical clearance. The individual can increase beyond moderate intensity following the principle of progression and those guidelines outlined in Chapter 8.

2. Asymptomatic individuals who do not participate in regular exercise with a known cardiovascular, metabolic, or renal disease should obtain medical clearance before starting an exercise program. Once cleared to exercise, he or she should begin at a light-to-moderate intensity and progress to higher intensities as tolerated.

3. Individuals who are symptomatic and do not currently exercise should seek medical clearance before participating in exercise. Following medical clearance, the individual may start an exercise program of light-to-moderate intensity.

4. Those individuals who do participate in regular exercise and do not have any known disease or sign or symptom suggestive of disease do not need any medical clearance and may begin an exercise program starting at a moderate-to-vigorous intensity or continue with their current exercise program.

5. Individuals who participate in regular exercise and are asymptomatic but have a diagnosed cardiovascular, metabolic, or renal disease do not need medical clearance when starting a moderate-intensity exercise program. However, it is recommended that if the intensity of exercise increases to vigorous, the individual should seek medical clearance. In addition, if these individuals experience resting or exertional symptoms of disease or any change in health status, they should visit with their health care providers.

6. An individual who participates in regular exercise but experiences any signs or symptoms suggestive of cardiovascular, metabolic, or renal disease should discontinue the current exercise program and obtain medical clearance before continuing exercising at any intensity.

FIGURE 3.2. Exercise Preparticipation Health Screening Questionnaire for Exercise Professionals. (From Magal M, Riebe D. New preparticipation health screening recommendations: what exercise professionals need to know. ACSM’s Health Fitness J. 2016;20[3]:22–7. Used with permission.)

Should an individual be identified for needing medical clearance, he or she should be referred to an appropriate physician or health care provider. The type of medical clearance is left to the discretion of the provider. Because there is no standardized screening test, procedures may vary from practitioner to practitioner and may be as simple as a verbal consultation or more in-depth with a resting or stress electrocardiogram/echocardiogram, detection of coronary artery calcification via computed tomography, or even nuclear medicine imaging or angiography. It is suggested that the exercise professional request written clearance with special instructions or restrictions (e.g., may not exercise over 8 metabolic equivalents [METs]). Continued communication between the provider and exercise professional is an essential component of this process and aids in the success of the individual’s exercise program.

Self-Guided Methods

Traditionally, self-administered preparticipation health screening involved the use of the Physical Activity Readiness Questionnaire (PAR-Q) and the American Heart Association [AHA]/ACSM Health/Fitness Preparticipation Screening Questionnaire. With the advent of ACSM’s new screening algorithm, the traditional questionnaires do not play as large a role in preparticipation screening because they relied heavily on risk factor classification. However, the PAR-Q was recently updated to the evidence-based Physical Activity Readiness Questionnaire for Everyone (PAR-Q+) (Fig. 3.3) and now includes a number of additional follow-up questions that guide the exercise professional in his or her preparticipation recommendations (36). The updated version was created to reduce barriers to exercise as well as to reduce the number of false positive screenings (17) and utilizes follow-up questions that allow the exercise professional to better tailor the ExR_x for the individual based on medical history and possible signs and symptoms. The PAR-Q+ may be used as a self-guided tool, but because of the additional questions, it may be prudent to have a qualified exercise professional assess the results.

FIGURE 3.3. Physical Activity Readiness Questionnaire for Everyone (PAR-Q+). (Reprinted with permission from the PAR-Q+ Collaboration and the authors of the PAR-Q+ [Dr. Darren Warburton, Dr. Norman Gledhill, Dr. Veronica Jamnik, and Dr. Shannon Bredin].)

Risk Stratification for Those in Cardiac Rehabilitation and/or Medical Fitness Facilities

Exercise professionals who work with patients with known CVD in exercise-based cardiac rehabilitation settings or medical fitness facilities are advised to conduct a much more in-depth stratification process (40) that is different from the previously presented preparticipation screening for the general public. Risk stratification criteria outlined in Box 3.1 from the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) (2) provide a guideline to assist in the assessment of clinical populations. The AACVPR guidelines provide recommendations for telemetry monitoring and exercise supervision for patients’ signs and symptoms or known disease. Clinical exercise professionals should be aware that the AACVPR guidelines do not take into account an individual with comorbidities (e.g., Type 2 diabetes mellitus, morbid obesity, severe pulmonary disease, and debilitating neurological or orthopedic conditions) and how their condition may require a modification in the patient’s monitoring or supervision during exercise. For example, a patient with CVD may require telemetry monitoring. If that same patient has Type 2 diabetes, the exercise professional would need to be aware of glucose monitoring as well as potential neuropathies.

Box 3.1	American Association of Cardiovascular and Pulmonary Rehabilitation Risk Stratification Criteria for Patients with Cardiovascular Disease
Lowest Risk
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 post-event/post-procedure myocardial ischemia
Absence of clinical depression
Moderate Risk
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%–49%
Highest Risk
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 blood pressure 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 post-event/post-procedure myocardial ischemia
Presence of clinical depression