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Section 03:

Pre-Exercise Evaluations

and Risk Factor Assessment

ACSM Guidelines: Chapter 3 Pre-Exercise Evaluations

ACSM Manual: Chapter 3 Risk Factor Assessments

HPHE 4450

Dr. Cheatham

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Purpose

The extent of medical evaluations necessarybefore exercise testing depends of the

assessment of risk.

For many persons, especially those with CAD orother cardiovascular disorders, the exercise test

and accompanying physical examination are

critical to the development of safe and effectiveexercise programs.

Not all persons warrant extensive testing

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In the clinical setting, pre-exercise testevaluations usually include:

Medical history (ACSM Guidelines, Box 3.1, P. 42)

Physical examination (ACSM Guidelines, Box 3.2, P.43)

Laboratory tests (ACSM Guidelines, Box 3.3, P. 44)

(Next slide)

We will focus on the blood lipid profile laboratory test

Purpose

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Laboratory Tests

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Laboratory Tests

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Blood Tests

Fasted (at least 12 hours) blood test results are relevant to

determining risk of:

Hypercholesterolemia (cholesterol)

Prediabetes (glucose)

Two options

1) Refer to local laboratory for testing

2) Purchase instrumentation to perform tests

Phlebotomythe practice of withdrawing blood from a blood

vessel into a blood collection tube

Insertion of needle into vein (larger-volume sample) Requires professional training

Finger puncture (smaller-volume sample) Sufficient for mini-analyzers

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Risk Factor - Lipids and Lipoproteins

Blood Lipid Profile: Total Cholesterol (TC)

Low-Density Lipoprotein (LDL) cholesterol Bad cholesterol

Transports cholesterol and triglycerides from the liver toperipheral tissues

High-Density Lipoprotein (HDL) cholesterol Good cholesterol

Can remove cholesterol from within arteries and transport it

back to the liver for excretion or re-utilization Ratios

TC/HDL: Desirable < 4.5 males, < 4.0 females

LDL/HDL: Average Risk 3.6 males, 3.2 females

Triglycerides

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LDL cholesterol is the primary target for cholesterollowering therapy

LDL cholesterol is a powerful risk factor for CAD and a

decrease in LDL markedly decreases the incidence of CAD

HDL cholesterol level is strongly and inversely

associated with the risk for CAD

There is growing evidence for a strong association

between elevated triglyceride levels and CAD risk


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Risk FactorBlood Glucose

Standards set by the American Diabetes

Association

Prediabetes risk factor = 100125 mg/dL

Normal values

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Risk Factor - Blood Pressure

Definition:

Force of blood against walls of the vasculature

created by contraction of the heart

Often assessed by indirect auscultation

Expressed in millimeters of mercury

Systolic blood pressure (SBP): Maximum pressure during

contraction (systole)

Diastolic blood pressure (DBP): Minimum pressure during

relaxation (diastole)

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The relationship between BP and risk for cardiovascular

events is continuous, consistent, and independent of

other risk factors.

For individuals 40 to 70 yrs of age:

Each increment of 20 mmHg in SBP or 10 mmHg in DBPdoubles the risk of cardiovascular disease

Lifestyle modification, including physical activity, weight

reduction, a DASH eating plan, and moderate alcohol

consumption are the cornerstones of antihypertensivetherapy.

Most patients who require drug therapy, require two or

more antihypertensive meds to achieve the goal BP.


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Theory of Blood PressureMeasurement by IndirectAuscultation

The inflated BP cuff occludes bloodflow, yielding no sound heard in the

stethoscope placed beyond theocclusion

Slow release of cuff pressure allowsthe driving pressure of the blood toforce the blood beyond the cuff and

yields the first sounds (turbulence)heard in the stethoscope (SBP)

Sounds cease with full opening ofthe artery as pressure continues todecline and turbulence no longerpresent (DBP)


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Korotkoff Sounds Phase 1: SBP

Initial onset of sound (clear, repetitive tapping)

Phase 2: Soft tapping, murmuring, or swishing Typically 10 to 15 mm Hg below phase 1

Phase 3: Crisp, loud tapping High pitch and intensity

Phase 4: True DBP Muffling of sound

Soft or blowing sound

Considered true DBP, especially during exercise

Phase 5: Clinical DBP Complete disappearance of sound

Typically within 8 to 10 mm Hg of phase 4

Should be recorded if it is significantly different from phase 5


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Resting Measurement Procedures: The patient should be seated with the

legs uncrossed

The BP measurement should be done

in a relaxed, comfortable setting White coat syndrome

An appropriate BP cuff should be used

Center the bladder over the brachial

artery and secure the appropriate BPcuff snugly at the level of the heart

Locate the brachial artery pulse in theantecubital fossa and place the

stethoscope bell over the artery

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Resting Measurement Procedures (contd): Quickly inflate the BP cuff to:

20 mm Hg above SBP (if known)

150 to 180 mmHg

Up to 30 mmHg above the disappearance of the radial pulse

Release pressure 2 to 3 mmHg per heartbeat or 2 to 5mmHg per second to the fifth Korotkoff sound

Deflate the cuff rapidly to zero after DBP is obtained

Record the SBP and DBP (fourth and fifth Korotkoffsounds if they are significantly different)

Wait at least 1 full minute and repeat Values should be within 5 mm Hg of each other; if not,

repeat


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Blood Pressure - Exercise

Not in your books.

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Blood Pressure - Exercise

Not in your books.

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Blood Pressure - Calculations

Mean arterial pressure (MAP) Represents the average BP in the arterial system

MAP = DBP + 1/3(SBP DBP)

Pulse pressure (PP) Related to stroke volume

PP = SBP - DBP

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Heart Rate

Heart rate can be measured by: Palpation

Auscultation

Telemetry (HR monitors/watches) Electrocardiography (ECG, EKG)

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Heart Rate - Palpation

Palpation: 30- or 60-sec counts are more

accurate for resting HR

15- or 30-sec counts are morecommon during exercise

Begin counting the first beat

felt as zero (e.g., 0, 1, 2, 3, 4. . .)

Avoid baroreceptor reflex at the

carotid artery

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Heart Rate - Exercise

Predicted Maximal HR: 220 - age

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Risk FactorObesity (BMI)

An excessive amount of body fat Recently considered a major, primary CAD risk

factor

For risk stratification purposes a height/weightcomparison (BMI) and waist circumference are

considered

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Assessment standardizations (height)

Performed with a stadiometer

Remove shoes and hat (if worn)

Stand erect, feet flat, heels touching

Heels, mid- and upper body parts are against the wall

Take and hold a normal breath, look straight

Horizontal headboard is lowered tothe top of the head

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Weight protocol

Scale calibration

Wear minimal clothing

Void bladder within 1 hour prior to measurement Ideal measurement is in the morning before meal

consumption

Variance in the above standards is acceptable withunderstanding of deviance between measured

weight and standardized body weight

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Body mass index = __Weight in kg__

(Height in meters)2

Example: BMI calculation for a 150-lb, 68-in. client:

150 pounds / 2.205 = 68.0 kg (convert lbs to kg)

68 inches 2.54 = 172.7 cm (convert in. to cm)

172.7 cm / 100 = 1.727 m (convert cm to m)

1.727 m 1.727 m = 2.98 m2 (convert m to m2)

BMI = 68.0 kg / 2.98 m2

= 22.8 kg.

m2

(divide kg by m2

)

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Risk FactorObesity (Waist Circ.)

Abdominal obesity is associated with greater risk Measurement protocol:

Technician stands to the right of the client

Measurement made on bare skin Measurement made at the end of a normal exhalation

Measuring tape is held parallel to the floor and flat

against skin

Take multiple measurements to determine smallest site

Mean of two measurements taken at this site is used

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Risk FactorObesity (Waist Circ.)

Incorrect

Correct

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Risk FactorObesity

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Risk FactorPhysical Activity

Most variable component of total daily energyexpenditure

Public heath guidelines advocate:

30 minutes of moderate-intensity activity, 5 days/week, or

20 minutes of vigorous-intensity exercise 3 days/week

Assessment goal is to identify those not

meeting threshold: Regularcontinuous for at least 3 months

Activity below this level constitutes a risk factorinactivity

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Contraindications to Exercise Testing

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Patients with absolute contraindications should notperform 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.

hphe 4450 - section 03

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