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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
Risk Factor - Lipids and Lipoproteins
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Risk Factor - Lipids and Lipoproteins
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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.
Risk Factor - Blood Pressure
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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)
Risk Factor - Blood Pressure
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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
Risk Factor - Blood Pressure
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Risk Factor - Blood Pressure
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
Risk Factor - Blood Pressure
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Risk Factor - Blood Pressure
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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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Risk FactorObesity (BMI)
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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Risk FactorObesity (BMI)
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Risk FactorObesity (BMI)
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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Risk FactorObesity (BMI)
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Risk FactorObesity (BMI)
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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Risk FactorPhysical Activity
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Risk FactorPhysical Activity
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Contraindications to Exercise Testing
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Contraindications to Exercise Testing
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Contraindications to Exercise Testing
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.