Health Appraisal and Risk Stratification

Question 1

Clinical Guidelines for Aerobic Exercise Prescription

Answer 1

• why conduct health screen and risk classification?
• identify individuals…at increased risk who need physician evaluation and testing before undergoing vigorous activity; with clinically significant disease who should be in a professionally-supervised program
• prescribe all exercise at level appropriate for the individual
• best practice consists of two broad components: preliminary health screening and risk classification and aerobic testing of some type (submaximal test, graded exercise test)

Question 2

Preliminary Health Screening and Risk Classification

Answer 2

• important to classify client’s health status and risk classification before testing and/or exercise prescription
• allows us to identify individuals for: need for medical exam prior to testing, clinically significant disease states, best test for their needs, contraindications for testing
• its inclusion makes it more likely the exercise prescription is appropriately individualized

Question 3

Self-Guided Screening

Answer 3

• PAR-Q and you
• designed to identify adults: for whom unsupervised physical activity might be inappropriate
• who should receive medical advice regarding the most suitable exercise modes
• represents minimal standard for entry into moderate-intensity exercise program

Question 4

PAR-Q

Answer 4

• 7 questions
• identifies individuals needing medical clearance before participation
• client’s answering “yes” to any question on PAR-Q should be referred to their physician for medical clearance
• older or sedentary individuals should always check with physician beforehand

Question 5

Self-Guided Screening

Answer 5

• other types of self-guided screening
• routine paperwork completed within scope of an office visit (MD, PT, NP)
• entry procedures at health/fitness or clinical exercise facility
• promotional physical activity materials designed for and distributed to the general public

Question 6

Professionally Guided Screening

Answer 6

• professionally trained, certified, and/or licensed personnel
• provides greater detail/discrimination regarding: chronic diseases, signs and symptoms, CVD risk factors
• consists of detailed medical history and risk stratification and higher level needs assessment of: medical exam, exercise testing, physician supervision, exercise treatment
• all clients in medical environment typically require to complete medical history questionnaire
• subject history and questionnaires completed and analyzed
• all clients in medical environment minimally need prior to exercise training and prescription (identify signs and symptoms of CV disease, analyze coronary risk profile, classify disease risk of client)

Question 7

Informed Consent

Answer 7

• include questions relating to family history
• include questions relating to lifestyle
• note current meds
• make physician referral if necessary

Question 8

Risk Stratification: What’s the Goal?

Answer 8

• use client information to classify risk level

- based on: known or suspected disease state, signs and symptoms, risk factors

Question 9

Risk Stratification: Low Risk

Answer 9

• no signs/symptoms
• less than two CVD risk factors
• in this population the odds of an acute CV event is low
• medical exam and clearance is not needed prior to starting exercise and/or max testing

Question 10

Risk Stratification: Moderate Risk

Answer 10

• no signs/symptoms
• two or more CVD risk factors
• in this population increased odds of an acute CV event
• low to moderate intensity physical activity, e.g. 40-60% VO2R, medical exam and clearance not required
• vigorous intensity physical activity, e.g. >/ 60% VO2R, medical exam and exercise test recommended, exercise test not required

Question 11

Risk Stratification: High Risk

Answer 11

• known CV, pulmonary, or metabolic disease
• one or more signs/symptoms
• in this population increased odds of acute CV event
• medical exam should take place and clearance given prior to physical activity at any intensity
• exercise test recommended
• MD supervision of exercise test? submax and at max answer is yes

Question 12

VO2 Max

Answer 12

-maximum amount of oxygen can take in while exercising aka aerobic capacity

Question 13

ACSM Risk Stratification Categories

Answer 13

• cardiovascular, pulmonary and metabolic disease
• major signs and symptoms suggestive of CV, pulmonary, and metabolic disease
• atheroscleroitc cardiovascular risk factors

Question 14

Cardiovascular, Pulmonary, and Metabolic Disease

Answer 14

• a physician has diagnosed one of the following
• CVD: cardiac, peripheral artery disease, or cerebrovascular disease
• pulmonary disease: COPD, asthma, interstitial lung disease, or CF
• metabolic disorders: diabetes mellitus (I or II), thyroid disorders, or renal or liver disease

Question 15

Major Signs and Symptoms Suggestive of CV, Pulmonary, and Metabolic Disease

Answer 15

• pain or other anginal equivalent: chest, neck, jaw, arms, other; ischemic origin: character, location, provoking factors; -non-ischemic origin: character, location, provoking factors
• dizziness
• dyspnea
• orthopnea
• palpitations
• intermittent claudication
• high prevalence of CAD
• diabetes: increased risk for PAD
• known heart murmur: hypertrophic cardiomyopathy
• unusual fatigue or SOB with usual activities

Question 16

Dizziness

Answer 16

• or syncope
• due to cardiac disorders: abnormal cardiac output, CAD, hypertrophic cardiomyopathy, aortic stenosis, malignant ventricular dysrhythmias
• reduction in venous return

Question 17

Dyspnea

Answer 17

• shortness of breath: risk or mild exertion, abnormal when at low intensity
• symptoms suggest: left ventricular dysfunction, COPD

Question 18

Orthopnea

Answer 18

• dyspnea at rest in recumbent position: relieved by sitting upright or standing
• paroxysmalnocturnal dyspnea: onset 2-5 hours after sleep-relieved by sitting on side of bed or getting out of bed
• symptoms suggest: LV dysfunction, COPD

Question 19

Palpitations

Answer 19

• unpleasant awareness of forceful or rapid heartbeats
• disorders of cardiac rhythm: tachycardia, ectopic beats
• anxiety

Question 20

Intermittent Claudication

Answer 20

• muscle pain secondary inadequate blood supply during activity
• atherosclerosis
• does not occur while sitting or standing
• reproductive
• pain resolved 1-2 minutes after cessation of activity

Question 21

Atherosclerotic Cardiovascular Risk Factors

Answer 21

• traits associated with increase in disease and other health-related event/condition: personal behavior, lifestyle, environmental exposure, inborn or inherited
• a variable that affects the probability of a specified adverse event

Question 22

CAD Risk Factor Thresholds

Answer 22

• clinically relevant threshold
• intended use is to aid in the identification of occult CAD
• provide threshold values for each risk factor

Question 23

Family History

Answer 23

• MI, CABG, sudden death
• before 55y in father or other 1st degree relative
• before 65y in mother or other 1st degree relative

Question 24

Cigarette Smoking

Answer 24

• current smoker or those who quit within the past 6 months

- second hand smoke kills

Question 25

Sedentary Lifestyle

Answer 25

- no participation in at least 30 minutes moderate activity 3+ days/week: 40-60% VO2R - for at least 3 months

Question 26

Obesity

Answer 26

- BMI>30 kg/m2 - waist girth: men greater than 102 cm, women greater than 88 cm - waist: hip ratio-men greater than or equal to .95, women greater than or equal to .86

Question 27

Hypertension

Answer 27

- greater than 140/90 mmHg - measured on 2 separate occasions or on antihypertensive medications - new guidelines less than 120/80 normal, greater than 120/80 pre-hypertensive

Question 28

Dyslipemia

Answer 28

- total cholesterol is greater than 200 mg/dl - HDL less than 40 mg/dl (good ones) - LDL greater than 130 mg/dl - or on lipid lowering medication

Question 29

Prediabetes

Answer 29

- impaired fasting blood glucose: greater than or equal to 100 mg/dl, less than or equal to 126 mg/dl - impaired glucose tolerance: given a dose of glucose, 2 hours value OGTT greater than or equal to 140 mg/dl or less than or equal to 200 mg/dl - either, confirmed on 2 separate tests

Question 30

Negative Risk Factor

Answer 30

- HDL-CHOL > 60 mg/dl | - subtract one risk factor from positive risk factors

Question 31

Dealing With Undisclosed or Unavailable Risk Factor Information

Answer 31

- adopt a conservative approach to CVD risk factor identification: safer to over-estimate, rather than under-estimate risk - risk factor info is missing and/or - criteria for identifying presence or absence of a specific risk factor cannot be determined or is not available - not disclosed or unavailable: risk factor should be counted as risk factor-exception: prediabetes - prediabetes: counted as a risk factor-age >/ 45y particularly with BMI >/25 kg/m2; age /25 kg/m2 and have additional risk factors for diabetes

Question 32

Exercise Testing and Supervision Recommendations Based on Risk Stratification

Answer 32

- once risk category has been established-recommendations made regarding the following - medical exam and clearance before initiating a physical activity/exercise program (substantially changing the FITT framework of an existing physical activity/exercise program) or - graded exercise test before initiating a physical activity/exercise program (or substantially change the FITT framework of an existing physical activity/exercise program) or - need for physician supervision when participating in a maximal or submaximal exercise test

Question 33

Exercise Testing and Supervision Recommendations Based on Risk Stratification-Criteria for Stratification

Answer 33

- moderate intensity exercise: 40-60% VO2R, 3-6 METS, prolonged steady state exercise - vigorous intensity exercise: > 60% VO2R, > 6 METS - not recommended - recommended - metabolic equivalent to being completely sedentary

Question 34

CAD Positive Risk Factors

Answer 34

- age (male >/45 female >/ 55) - family history - current cigarette smoking - obesity - sedentary lifestyle - hypertension - dyslipidemia - prediabetes