Pre-Screening and Risk Stratification

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1 Pre-Screening and Risk Stratification Chapter 1, 2 and 3 ACSM What is involved in the prescreening process? The Basic Goal To determine if it is safe for an individual to start an exercise program, what type of exercise testing is appropriate, and what medical supervision is necessary. 1

2 What is the process? 1. If in a clinical setting, obtain informed consent. 2. A form of medical and health history 3. What goals for activity does the person have? (this is important!!!) 4. Risk Stratify the client. 5. Decided whether it is recommended to do a physical exam, exercise test the person, AND what type of test is appropriate. 6. Decide if your facility can test the person by.. Documentation Results of screening Document communication with healthcare professionals Physician referral form Exercise prescription Emergency procedures Pre-participation Screening Informed Consent (pg 52 example) PAR-Q* - minimal standard Physical Exam findings Lung sounds Heart sounds Laboratory Tests Blood Blood pressure Pulmonary Function 2

3 Informed Consent Should be conveyed both verbally and written Explanation of procedure/program Risks & Benefits Responsibilities of participant Confidentiality (lock and key) Documentation of questions and answers Documentation of acceptance Freedom of consent (sign and initial) Other Forms Assumption of Risk form Potential client declines to complete screening forms but still wants to participate Physician s approval form (medical clearance) Emergency Medical Authorization - minors FIGURE 2-1, ACSM Guidelines 3

4 In chapter 3 it discuses the exercise program and how you should present a consent and explain to the participants that they may stop if they want to. What do you do in a case that they do not want to stop but you see the test may bring bodily harm? Pre-participation Screening Medical History Diagnoses Hospitalizations/ Surgery Medications (action, dose) Taking meds regularly Family Hx Risk Factors* Current Physical Activity Hx Previous exercise test findings Frequency, Type, signs and symptoms (SxS) (Box 2-1) Veteran s Specific Activity Questionnaire 4

5 Pre-participation Screening (con t) Risk Factors (Table 2-2) KNOW!!!!!!!! Family History Cigarette Smoking Hypertension Hypercholesterolemia Impaired fasting glucose Obesity Sedentary lifestyle Negative Risk Factor High serum HDL Atherosclerotic Cardiovascular Disease Risk Factors Atherosclerotic Cardiovascular Disease Risk Factors 5

6 Atherosclerotic Cardiovascular Disease Risk Factors Case Study #1 This is a 51 year old white female, height 66, weight 170 pounds. She is a retired Army officer. She has smoked approximately 2 packs of cigarettes per day for the last thirtyfive years. Present activities include golf (walking with clubs) and tennis, each 2 days/week. No history of CAD in her family. The client complains of shortness of breath. Present BP is 158/90 mm Hg and RHR is 75 bpm. TC = 189 mg/dl, LDL = 139 mg/dl, HDL = 39 mg/dl, glucose = 100 mg/dl. She drinks approximately 2 glasses daily Veterans Specific Activity Questionnaire (VSAQ) 6

7 Physical Activity Screening - Symptoms Which of the following SxS do you have with exertion? (Table 2.2) Chest discomfort or pain or in surrounding area Type, when, severity Shortness of breath (SOB) Dizziness or syncope Palpitations or tachycardia Claudication (pain in legs) Angina Demand > Supply Diagnosis (DX) stress testing, angiography Treatment Pharmacologic Secondary Risk Reduction Exercise based on symptomology AHA Symptomology Chest discomfort. Most heart attacks involve discomfort in the center of the chest that lasts more than a few minutes, or that goes away and comes back. It can feel like uncomfortable pressure, squeezing, fullness or pain. Discomfort in other areas of the upper body. Symptoms can include pain or discomfort in one or both arms, the back, neck, jaw or stomach. Shortness of breath. May occur with or without chest discomfort. Other signs: These may include breaking out in a cold sweat, nausea or lightheadedness 7

8 Types of Angina and Associated Pathophysiology Typical Angina evoked by exertion, emotions, cold/heat exposure, meals, and sexual intercourse; relieved by rest or nitroglycerin Stable Angina reproducible and predictable in onset Atypical Angina no relationship to exertion Unstable Angina new onset of typical angina, increasing in intensity or occurs at rest Variant (Prinzmetal s angina) - Physical Activity Screening - Symptoms Physical Activity Screening - Symptoms Orthopnea or paroxysmal nocturnal dyspnea Known heart murmur Unusual fatigue or shortness of breath with usual activities 8

9 Major Signs/Symptoms Suggestive of Cardiovascular, Pulmonary, and Metabolic Disease Table 2-2 Table 2-1 Risk Stratification Risk Stratification (cont.) Figure 2-3 9

10 Need a physical exam and exercise test? What type of test is recommended? If an individual has a known cardiovascular disease, is it at all possible for them to be able to participate regularly in an exercise program to achieve and maintain a fit or at least a healthy lifestyle? Exercise Testing and Testing Supervision Recommendations Based Upon Risk Category IMPORTANT!! Secondary Risk Stratification (for those who already have a medical diagnoses) AACVPR Low risk stable, functional capacity > 6 METs, EF > 50%, symptoms may occur at high MET levels Moderate EF = 40 50%, reduced functional capacity (5-6 METs) with SxS High unstable, poor ventricular function, SxS below 5 METs AHA Class A, B, C, and D 10

11 Indications for Exercise Testing- 1. Diagnosis SxS Exercise induced SxS Angina Old or new ECG abnormalities 2. Prognosis Use to predict mortality 3. Exercise Capacity, Prescription 4. Evaluate Rx Outcomes (Froelicher. Handbook of Exercise Testing.1996 Contraindications to Exercise Testing Do the risks of exercise testing outweigh indications? Absolute under no circumstances* should the test be performed Relative must weigh with indications for testing to determine outcome Contraindications to Exercise Testing Box

12 Contraindications to Exercise Testing Box 3-5 Contraindications to Exercise Testing (cont.) Risk/Benefit 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. 12

13 Contraindications to Exercise Testing (cont.) The exercise test may still provide useful information on: exercise capacity, dysrhythmias, and hemodynamic responses to exercise. In these conditions, additional evaluative techniques such as respiratory gas exchange analyses, echocardiography, or nuclear imaging can be added. Normal High degree heart block High degree Heart block Contraindications for Exercise Testing Relative (Know!!)... Testing Facility (Emergency Procedures) Need appropriate equipment (AHA) Defibrillator? Airway / oxygen Drugs Phone Need appropriate staff Physician EMT/nurse Exercise Specialist SM or equivalent experience 13

14 Participant Instructions Participants should refrain from ingesting food, alcohol, or caffeine or using tobacco products within 3 hours 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. Participant Instructions (cont.) If the evaluation is on an outpatient basis, participants should be made aware that the evaluation may be fatiguing and that they may wish to have someone accompany them to the assessment to drive them home afterward. Participant Instructions (cont.) If the 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 betablocking agents may be asked to taper their medication over a 2- to 4-day period to minimize hyperadrenergic withdrawal responses. 14

15 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. 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- hour period preceding the test to ensure normal hydration before testing. Case Study #1 Should we do GXT and what type? Jerry Attrik 67 yr old Caucasian male, recently retired Not active Wt = 217 lbs Ht = 68 in 125 cm waist circumference Medications - Atenolol ( beta blocker), Ibuprofen Heart Catheterization 2 years ago: results unknown Family Hx Father diagnosed with CAD Disease at Age 40 Resting BP 128/88 Total Cholesterol 230 mg/dl no other information on blood work is available Reports being tense and overstressed often Reports frequent episodes of chest tightness while mowing the lawn. 15

16 Case Study #2 Does she need a physical exam and exercise test? Moram Ovement 25 yr old Hispanic female Wt = 157 lbs Ht = 62 in 30 percent body fat She is going to join LA Fitness and go to their aerobics classes. She is a friend of yours and heard that you were an exercise science major. She wants advice on getting started and losing weight. She has never participated in a regular exercise program of any type. She currently smokes a few cigarettes a day. Her resting blood pressure is 138/86. Her blood parameters are all below risk level and she has no family history of CAD. 16

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