2 Exercise

Preparticipation
Health Screening

INTRODUCTION
Historically, the exercise preparticipation health screening process centered on
the risk classification (i.e., low, moderate, high) of all individuals which was
based on (a) the number of cardiovascular disease (CVD) risk factors and (b) the
presence of signs or symptoms and/or known cardiovascular (CV), metabolic,
and/or pulmonary disease. Recommendations for a preparticipation medical
examination and exercise testing were then based on the risk classification and
proposed exercise intensity. These recommendations were designed to avoid
exposing habitually inactive individuals with known or occult CVD to the
transiently heightened risks of unaccustomed vigorous intensity exercise,
including sudden cardiac death (SCD) and acute myocardial infarction (AMI) as
discussed in Chapter 1.
Although the overarching goal of exercise preparticipation health screening
remains the same as in the previous editions of the Guidelines, the updated
version of Chapter 2:
Bases the exercise preparticipation health screening process on (a) the
individual’s current level of physical activity (PA); (b) the presence of signs
or symptoms and/or known CV, metabolic, or renal disease; and (c) the
desired exercise intensity because these three factors have been identified as
important risk modulators of exercise-related CV events.
No longer includes the CVD risk factor profile as part of the decision making
 for referral to a health care provider prior to the initiating a moderate-to-
vigorous intensity exercise program.
No longer recommends a low, moderate, or high risk classification scheme.
Makes general recommendations for medical clearance versus specific
recommendations for medical exams or exercise tests, leaving the manner of
clearance to the discretion of the health care provider.
Does not automatically refer individuals with pulmonary disease for medical
clearance prior to the initiation of an exercise program.
This edition of the Guidelines not only continues to encourage
preparticipation health screening for persons interested in initiating or
progressing exercise or other PA programs but also seeks to further simplify the
preparticipation health screening process that was updated in the ninth edition in
order to remove unnecessary barriers to adopting a physically active lifestyle
(23). This edition of the Guidelines also continues to recommend that exercise
professionals consult with their medical colleagues when there are questions
about patients with known disease or signs and symptoms suggestive of disease
or any other concern about an individual’s ability to safely participate in an
exercise program. The new exercise preparticipation health screening
recommendations are not a replacement for sound clinical judgment, and
decisions about referral to a health care provider for medical clearance prior to
the initiation of an exercise program should continue to be made on an
individual basis.
This updated preparticipation process is based on the outcomes of a scientific
roundtable sponsored by the American College of Sports Medicine (ACSM) in
2014 (25). The expert panel unanimously agreed that the relative risk of a CV
event is transiently increased during vigorous intensity exercise as compared
with rest but that the absolute risk of an exercise-related acute cardiac event is
low in healthy asymptomatic individuals (see Figure 1.2) (1,15,19,20,28–30,35).
Accordingly, preparticipation screening was deemed necessary, but screening
recommendations needed refinement to better reflect the state of the science and
reduce potential barriers to the adoption of PA. The new evidence-informed
model for exercise preparticipation health screening is based on a screening
algorithm with recommendations for medical clearance based on an individual’s
current PA level, presence of signs or symptoms and/or known CV, metabolic, or
renal disease, and the anticipated or desired exercise intensity (25). These factors
are included because among adults, the risk for activity-associated SCD and
AMI is known to be highest among those with underlying CVD who perform
unaccustomed vigorous PA (7,20,29). The relative risk of SCD and AMI during
vigorous-to-near maximal intensity exercise is directly related to the presence of
CVD and/or exertional symptoms (29) and is inversely related to the habitual
level of PA (1,2,5,8,20,23,24). The relative and absolute risks of an adverse CV
event during exercise are extremely low even during vigorous intensity exercise
in asymptomatic individuals (26,28,30).
Insufficient evidence is available to suggest that the presence of CVD risk
factors without underlying disease confers substantial risk of adverse exercise-
related CV events. The high prevalence of CVD risk factors among adults (36),
combined with the rarity of exercise-related SCD and AMI (28,29), suggests that
the ability to predict these rare events by assessing risk factors is low, especially
among otherwise healthy adults (29,31). Furthermore, recent evidence suggests
that conventional CVD risk factor–based exercise preparticipation health
screening may be overly conservative due to the high prevalence of risk factors
and may generate excessive physician referrals, particularly in older adults (36).
Although removed from preparticipation screening, this edition of the Guidelines
affirms the importance of identifying and controlling CVD risk factors as an
important objective of overall CV and metabolic disease prevention and
management. Exercise professionals are encouraged to complete a CVD risk
factor assessment with their patients/clients as part of the preexercise evaluation
(see Chapter 3). Regardless of the number of risk factors, the exercise
professional should use clinical judgment and make decisions about referral to a
health care provider for medical clearance on an individual basis.
The decision to recommend general medical clearance rather than medical
examination or exercise testing builds on changes introduced in the ninth edition
of the Guidelines and is intended to better align with recent relevant evidence
that exercise testing is not a uniformly recommended screening procedure. As
noted in the ninth edition of the Guidelines, exercise testing is a poor predictor
of acute cardiac events in asymptomatic individuals. Although exercise testing
may detect flow-limiting coronary lesions via the provocation of ischemic ST-
segment depression, angina pectoris, or both, SCD and AMI are usually
triggered by the rapid progression of a previously nonobstructive lesion (29).
Furthermore, lack of consensus exists regarding the extent of the medical
evaluation (i.e., physical exam; peak or symptom-limited exercise testing)
needed as part of the preparticipation health screening process prior to initiating
an exercise program, even when the program will be of vigorous intensity. The
American College of Cardiology (ACC)/American Heart Association (AHA)
recommend exercise testing prior to moderate or vigorous intensity exercise
programs when the risk of CVD is increased but acknowledge that these
recommendations are based on conflicting evidence and divergent opinions (9).
The U.S. Preventive Services Task Force recommends against the use of routine
diagnostic testing or exercise electrocardiography as a screening tool in
asymptomatic individuals who are at low risk for CVD events and concluded
that there is insufficient evidence to evaluate the benefits and harm of exercise
testing before initiating a PA program. Furthermore, the U.S. Preventive Services
Task Force did not make specific recommendations regarding the need for
exercise testing for individuals at intermediate and high risk for CVD events
(22). Similarly, others have emphasized that randomized trial data on the clinical
value of exercise testing for screening purposes are absent; in other words, it is
presently not known if exercise testing in asymptomatic adults reduces the risk
of premature mortality or major cardiac morbidity (17). The 2008 Physical
Activity Guidelines Advisory Committee Report to the Secretary of Health and
Human Services (23) states that “symptomatic persons or those with
cardiovascular disease, diabetes, or other active chronic conditions who want to
begin engaging in vigorous PA and who have not already developed a PA plan
with their health care provider may wish to do so” but does not mandate medical
clearance. There also is evidence from decision analysis modeling that routine
screening using exercise testing prior to initiating an exercise program is not
warranted regardless of baseline individual risk (16). These considerations and
other recent reports (10,23) further shaped the present ACSM recommendation
that the inclusion of exercise testing or any other type of exam, as part of
medical clearance, should be left to the clinical judgment of qualified health care
providers.
In the new exercise preparticipation health screening procedures, individuals
with pulmonary disease are no longer automatically referred for medical
clearance because pulmonary disease does not increase the risks of nonfatal or
fatal CV complications during or immediately after exercise; in fact, it is the
associated inactive and sedentary lifestyle of many patients with pulmonary
disease that may increase the risk of these events (13). However, chronic
obstructive pulmonary disease (COPD) and CVD are often comorbid due to the
common risk factor of smoking, and the presence of COPD in current or former
smokers is an independent predictor of overall CV events (6). Thus, careful
attention to the presence of signs and symptoms of CV and metabolic disease is
warranted in individuals with COPD during the exercise preparticipation health
screening process. Nevertheless, despite this change, the presence of pulmonary
or other diseases remains an important consideration for determining the safest
and most effective exercise prescription (Ex Rx) (25).
The goals of the new ACSM exercise preparticipation health screening
process are to identify individuals (a) who should receive medical clearance
before initiating an exercise program or increasing the frequency, intensity,
and/or volume of their current program; (b) with clinically significant disease(s)
who may benefit from participating in a medically supervised exercise program;
and (c) with medical conditions that may require exclusion from exercise
programs until those conditions are abated or better controlled. This chapter
provides guidance for using the new exercise preparticipation health screening
algorithm with respect to:
Determining current PA levels
Identifying signs and symptoms of underlying CV, metabolic, and renal
disease (Table 2.1)
 Identifying individuals with diagnosed CV and metabolic disease
Using signs and symptoms, disease history, current exercise participation, and
desired exercise intensity to guide recommendations for preparticipation
medical clearance
By following a preparticipation screening algorithm taking into account the
preceding points, exercise professionals are better able to identify participants
who are at risk for exercise- or PA-related CV complications. The algorithm is
designed to identify individuals who should receive medical clearance before
initiating an exercise program or increasing the frequency, intensity, and/or
volume of their current program and may also help to identify those with
clinically significant disease(s) who may benefit from participating in a
medically supervised exercise program and those with medical conditions that
may require exclusion from exercise programs until those conditions are abated
or better controlled (18,25).

PREPARTICIPATION HEALTH SCREENING

The following section provides guidance for preparticipation screening for
exercise professionals working with the general, nonclinical population.
Recommendations for those individuals who are working in a clinical or cardiac
rehabilitation setting are presented separately, later in the chapter.
Preparticipation health screening before initiating PA or an exercise program
is a two-stage process:
1. The need for medical clearance before initiating or progressing exercise
programming is determined using the updated and revised ACSM screening
algorithm (see Figure 2.2) and the help of a qualified exercise or health care
professional. In the absence of professional assistance, interested individuals
may use self-guided methods (discussed later).
2. If indicated during screening (see Figure 2.2), medical clearance should be
sought from an appropriate health care provider (e.g., primary care or internal
medicine physician, cardiologist). The manner of clearance should be
determined by the clinical judgment and discretion of the health care provider.
Preparticipation health screening before initiating an exercise program should
be distinguished from a periodic medical examination (23), which should be
encouraged as part of routine health maintenance.

SELF-GUIDED METHODS
Preparticipation health screening by a self-screening tool should be done for all
individuals wishing to initiate an exercise program. A notable change in this
section is the omission of the Physical Activity Readiness Questionnaire (PAR-
Q) and AHA/ACSM Health/Fitness Facility Preparticipation Screening
Questionnaire and the addition of the PAR-Q+ (3,34). The traditional
AHA/ACSM questionnaire was excluded because it relies heavily on risk factor
profiling which is no longer a part of the exercise preparticipation health
screening process. The PAR-Q was recently updated to the PAR-Q+ (Figure
2.1), which now includes several additional follow-up questions to better guide
preparticipation recommendations (34). The updated PAR-Q+ is evidence-based
and was developed, in part, to reduce barriers for exercise and false positive
screenings (14). The tool uses follow-up questions to better tailor preexercise
recommendations based on relevant medical history and symptomatology. The
PAR-Q+ may be used as a self-guided exercise preparticipation health screening
tool or as a supplemental tool for professionals that may want additional
screening resources beyond the new algorithm. Notably, the cognitive ability
required to fully answer the PAR-Q+ may be higher than the original PAR-Q;
thus, some individuals may need assistance completing the PAR-Q+.
AMERICAN COLLEGE OF SPORTS MEDICINE
PREPARTICIPATION SCREENING ALGORITHM
The ACSM preparticipation screening algorithm (Figure 2.2) is a new
instrument designed to identify participants at risk for CV complications during
or immediately after aerobic exercise. Although resistance training is growing in
popularity (32), current evidence is insufficient regarding CV complications
during resistance training to warrant formal prescreening recommendations.
Because there are few data regarding CV complications during resistance
training, this risk cannot currently be determined but appears to be low
(10,11,38).
Algorithm Components
The screening algorithm (see Figure 2.2) begins by classifying individuals who
do or do not currently participate in regular exercise. The intent is to better
identify those individuals unaccustomed to regular physical exertion for whom
exercise may place disproportionate demands on the CV system and increase the
risk of complications. As designated, participants classified as current exercisers
should have a history of performing planned, structured PA of at least moderate
intensity for at least 30 min on three or more days per week during the past 3
mo.
The next level of classification involves identifying individuals with known
CV, metabolic, or renal diseases or those with signs or symptoms suggestive of
cardiac, peripheral vascular, or cerebrovascular disease, Types 1 and 2 diabetes
mellitus (DM), and renal diseases. During the preparticipation screening process,
participants should be asked if a physician or other qualified health care provider
has ever diagnosed them with any of these conditions. During preparticipation
health screening, hypertension should be considered a CVD risk factor and not a
cardiac disease (4). Refer to Chapter 3 for additional information on CVD risk
factor appraisal.
Once an individual’s disease status has been ascertained, attention should shift
toward signs and symptoms suggestive of these diseases. The CV, metabolic, and
renal diseases of concern for preparticipation health screening may be present
but undiagnosed in exercise participants. To better identify those individuals who
may have undiagnosed disease, participants should be screened for the presence
or absence of signs and symptoms suggestive of these diseases, as described in
Table 2.1. Care should be taken to interpret the signs and symptoms within the
context of the participant’s recent history, and additional information should be
sought to clarify vague or ambiguous responses. For example, a participant may
describe recent periods of noticeable breathlessness. This occurrence is a
nonspecific symptom of CVD as many factors can cause shortness of breath.
Pertinent follow-up questions may include “What were you doing during these
periods?” or “Were you more breathless than you would have expected for this
activity?” These questions may provide better clarification to better distinguish
expected from potentially pathological signs and symptoms. An exercise
preparticipation health screening checklist (Figure 2.3) is included to guide the
exercise professional through the prescreening process.
 Desired exercise intensity is the final component in the preparticipation
screening algorithm. Because vigorous intensity exercise is more likely to trigger
acute CV events, versus light-to-moderate intensity exercise, in selected
individuals (20,29), identifying the intensity at which a participant intends to
exercise is important. Guidance is offered in the footnotes of the algorithm on
the aforementioned designations as well as what constitutes light, moderate, and
vigorous intensity exercise. Additional information on exercise intensity can be
found in Table 6.1.

Using the Algorithm

According to the preparticipation screening algorithm, participants are grouped
into one of six categories. Each category is explained later, moving from left to
right across Figure 2.2. Importantly, exercise professionals using this algorithm
should monitor participants for changes that may alter their categorization and
recommendations. For example, participants who initially declare no signs or
symptoms of disease may develop signs or symptoms only after beginning an
exercise program, and this would necessitate more aggressive screening
recommendations.
Apparently, healthy participants who do not currently exercise and have no
history or signs or symptoms of CV, metabolic, or renal disease can
immediately, and without medical clearance, initiate an exercise program at
light-to-moderate intensity. If desired, progression beyond moderate intensity
should follow the principles of Ex Rx covered in Chapter 6.
Participants who do not currently exercise and have (a) known CV, metabolic,
or renal disease and (b) are asymptomatic should obtain medical clearance
before initiating a structured exercise program of any intensity. Following
medical clearance, the individual may embark on light-to-moderate intensity
exercise and progress as tolerated following ACSM Guidelines.
Symptomatic participants who do not currently exercise should seek medical
clearance regardless of disease status. If signs or symptoms are present with
activities of daily living, medical clearance may be urgent. Following medical
clearance, the individual may embark on light-to-moderate intensity exercise
and progress as tolerated following ACSM Guidelines (see Chapter 6).
Participants who already exercise regularly and have no history or signs or
symptoms of CV, metabolic, or renal disease may continue with their current
exercise volume/intensity or progress as appropriate without medical
clearance.
Participants who already exercise regularly; have a known history of CV,
metabolic, or renal disease; but have no current signs or symptoms (i.e., are
clinically “stable”) may continue with moderate intensity exercise without
 medical clearance. However, if these individuals desire to progress to
vigorous intensity aerobic exercise, medical clearance is recommended.
Participants who already exercise regularly but experience signs or symptoms
suggestive of CV, metabolic, or renal disease (regardless of disease status)
should discontinue exercise and obtain medical clearance before continuing
exercise at any intensity.
When participants are identified for whom medical clearance is warranted,
they should be referred to an appropriate physician or other health care provider.
Importantly, the type of medical clearance is left to the discretion and clinical
judgment of the provider to whom the participant is referred because there is no
single, universally recommended screening test. The type of procedures
conducted during clearance may vary widely from provider to provider and may
include verbal consultations, resting or stress electrocardiogram
(ECG)/echocardiogram, computed tomography for the assessment of coronary
artery calcium, or even nuclear medicine imaging studies or angiography.
Exercise professionals may request written clearance along with special
instructions or restrictions (e.g., exercise intensity) for the participant in
question, and continued communication between health care providers and
exercise professionals is strongly encouraged. To better understand the
preparticipation screening algorithm, case studies are presented in Box 2.1.

Case Studies to Determine Need for Exercise Preparticipation

Box 2.1
Medical Clearance

CASE STUDY I
A 50-yr-old nonsmoking male was recently invited by colleagues to
participate in a 10-km trail run. He reports currently walking 40 min on
Monday, Wednesday, and Friday — something he has done “for years.” His
goal is to run the entire race without stopping, and he is seeking training
services. He reports having what he describes as a “mild heart attack” at 45 yr
old, completed cardiac rehabilitation, and has had no problems since. He takes
a statin, an angiotensin-converting enzyme (ACE) inhibitor, and aspirin daily.
During the last visit with his cardiologist, which took place 2 yr ago, the
cardiologist noted no changes in his medical condition.
CASE STUDY II
A 22-yr-old recent college graduate is joining a gym. Since becoming an
accountant 6 mo ago, she no longer walks across campus or plays intramural
soccer and has concerns about her now sedentary lifestyle. Although her body
mass index (BMI) is slightly above normal, she reports no significant medical
history and no symptoms of any diseases, even when walking up three flights
of stairs to her apartment. She would like to begin playing golf.
CASE STUDY III
A 45-yr-old former collegiate swimmer turned lifelong triathlete requests
assistance with run training. His only significant medical history is a series of
overuse injuries to his shoulders and Achilles tendon. In recent weeks, he
notes his workouts are unusually difficult and reports feeling constriction in
his chest with exertion — something he attributes to deficiencies in core
strength. Upon further questioning, he explains that the chest constriction is
improved with rest and that he often feels dizzy during recovery.
CASE STUDY IV
A 60-yr-old woman is beginning a professionally led walking program. Two
years ago, she had a drug-eluting stent placed in her left anterior descending
coronary artery after a routine exercise stress test revealed significant ST-
segment depression. She completed a brief cardiac rehabilitation program in
the 2 mo following the procedure but has been inactive since. She reports no
signs or symptoms and takes a cholesterol-lowering statin and antiplatelet
medications as directed by her cardiologist.
CASE STUDY V
A 35-yr-old business consultant is in town for 2 wk and seeking a temporary
membership at a fitness club. She and her friends have been training for a
long-distance charity bike ride for the past 16 wk; she is unable to travel with
her bike and she does not want to lose her fitness. She reports no current
symptoms of CV or metabolic disease and has no medical history except
hyperlipidemia, for which she takes a HMG-CoA reductase inhibitor (statin)
daily.
RISK STRATIFICATION FOR PATIENTS IN CARDIAC
REHABILITATION AND MEDICAL FITNESS FACILITIES
Previous sections in this chapter presented a preparticipation screening algorithm
for the general, nonclinical public. Exercise professionals working with patients
with known CVD in exercise-based cardiac rehabilitation and medical fitness
settings are advised to use more in-depth risk stratification procedures (37). Risk
stratification criteria from the American Association of Cardiovascular and
Pulmonary Rehabilitation (AACVPR) are presented in Box 2.2 (37).

American Association of Cardiovascular and Pulmonary

Box 2.2 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 postevent/postprocedure 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, 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 postevent/postprocedure myocardial
ischemia
Presence of clinical depression
Reprinted from (37), with permission from Elsevier.

The AACVPR guidelines provide recommendations for participant and/or

patient monitoring and exercise supervision and for activity prescription and
restriction. Clinical exercise professionals should recognize that the AACVPR
guidelines do not consider comorbidities (e.g., Type 2 DM, morbid obesity,
severe pulmonary disease, debilitating neurological and orthopedic conditions)
that may require modification of the recommendations for monitoring and
supervision during exercise training.

SUMMARY
The ACSM updated preparticipation health screening algorithm (see Figure
2.2) was developed for exercise professionals to systematically determine a
participant’s need for medical clearance prior to beginning an exercise
program.
The need for medical clearance prior to beginning an exercise program is
based on current exercise participation; history of CV, metabolic, or renal
disease; signs or symptoms suggestive of CV, metabolic, or renal disease (see
Table 2.1); and desired exercise intensity.
Individuals initiating exercise without assistance or outside of fitness facilities
may choose to use the PAR-Q+ (see Figure 2.1) as a self-screening tool.
The methods or procedures used for clearance are left to the discretion of the
medical provider.
 Cardiac rehabilitation and medical fitness facilities are encouraged to use the
AACVPR stratification presented in Box 2.2.
The purpose of preparticipation health screening is to identify individuals who
are at risk for adverse exercise-related CV events. Overall, there is a low risk of
SCD and AMI associated with participation in an exercise program and much of
the risk associated with vigorous exercise is mitigated by adopting a progressive
transitional phase (~2–3 mo) during which the duration and intensity of exercise
are gradually increased (23,25). When previously sedentary individuals initiate
an exercise program, such individuals are strongly recommended to begin with
light-to-moderate intensity (e.g., 2–3 metabolic equivalents [METs]) and
gradually increase the intensity of exertion (e.g., 3–5 METs) over time, provided
that the individual remains symptom free. Such a gradual progression appears
prudent because these intensities are below the vigorous intensity threshold (≥6
METs) that is commonly associated with the triggering of acute CV events in
susceptible individuals (21,29). This “progressive transitional phase” will help to
minimize the risk of musculoskeletal injury as well as allow sedentary
individuals to improve their cardiorespiratory fitness without going through a
period during which each session of vigorous exercise is associated with large
spikes in relative CV risk (27).

ONLI NE RESOURCES
ACSM ExeRxcise is Medicine:
http://exerciseismedicine.org
2008 Physical Activity Guidelines for Americans:
http://www.health.gov/PAguidelines

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