Major Coronary Risk Factors & Pre-Participation Guidelines ___________________

1. Major Coronary Risk Factors& Pre-Participation Guidelines___________________ As Established by the American College of Sports Medicine

2. What is a Risk Factor ? • An aspect of personal behavior or lifestyle, an environmental exposure or inherited characteristic, which, on the basis of epidemiological evidence, is known to be associated with health-related conditions considered to be important to prevent.

3. The Realm of Risk Factor Modification • Primary Prevention - intervention prior to the onset of CAD • Secondary Prevention - intervention after the onset of CAD

4. The Purposes for Pre-Participation Health ScreeningsReview of ACSM Guidelines 1. To identify and exclude individuals with medical contraindications to exercise. 2. To identify persons with clinically significant disease conditions who should be referred to a medically supervised exercise program. 3. To identify individuals with disease symptoms and risk factors for disease development who should receive further medical evaluation before starting an exercise program. 4. To identify persons with special needs for safe exercise participation (e.g., elderly persons, pregnant women).

5. Health Screening DevicesBy order of cost and complexity • Self administered health questionnaire • Par Q • Analysis of CAD Risk Profile • Physical exam by a physician • Basic diagnostic Exercise Testing (GXT) • Advanced diagnostic exercise testing (Nuclear stress, Stress Echo, Pharmacological Stress)

6. Risk Factors for CADAmerican College of Sports Medicine • Positive Risk Factors • Age • Family History • Cigarette Smoking • Hypertension • Hypercholesterolemia • Diabetes Mellitus • Sedentary Lifestyle/Activity • Negative Risk FactorsHigh Serum HDL Cholesterol

7. Risk Factors for CAD American College of Sports Medicine • Table 2-1 Page 24 in Guidelines or Page 19 in Heyward.

8. Risk Factors • Count the number of positive risk factors and subtract the number of negative risk factors

9. Risk Factors for CADAmerican College of Sports Medicine Family History • At risk if Coronary Disease is present in the form of MI or Sudden Death: • Father or Brother (1st degree relative) prior to the age of 55. • Mother or Sister (1st degree relative) prior to the age of 65.

10. Risk Factors for CADAmerican College of Sports MedicineCigarette/Cigar Smoking • At risk if, • Current use is present. • Residual effects may be manifest even if smoking has stopped Removal of Risk (?) Cessation for > 2-6 months

11. Risk Factors for CADAmerican College of Sports MedicineBlood Pressure • Resting Blood Pressure > 140/90 mm Hg • confirmed by 2 separate measurements (6th congress on hypertension) • “systolic>140 or diastolic >90” • Current Prescription for Blood Pressure Medicine (for hypertensive diagnosis)

12. Blood Pressure: Systolic Diastolic Optimal <120 <80 Normal 120-129 80-84 High Normal 130-139 85-89 Hypertension: Stage 1 140-159 90-99 Stage 2 160-179 100-109 Stage 3 >180 >110

13. Risk Factors for CADAmerican College of Sports MedicineHypercholesterolemia (Positive Risk) • On lipid lowering meds • If Lipoprotein profile is not available • at risk with Total Cholesterol > 200 mg/dL • If Lipoprotein profile is available • at risk with HDL cholesterol < 35 mg/dL • LDL>130

14. Risk Factors for CADAmerican College of Sports MedicineHypercholesterolemia (Negative Risk) • Lipoprotein profile must be available. • Subtract one risk factor if HDL cholesterol is > 60 mg/dL

15. Risk Factors for CAD American College of Sports MedicineDiabetes Mellitus • At Risk if: diagnosed with DM and conditions below are unmet (fasting glucose is >110 mg/dl on two occasions) Classified as Known Disease: • diagnosed with Type 1 for more than 15 years or • diagnosed with Type 1 & age > 30 or • diagnosed with Type 2 and age > 35

16. Risk Factors Other risk factors: • Obesity (AHA) BMI>30 or waist of >100 cm for men and >88 for women • Use your best judgement due to the controversy

17. Risk Factors for CADAmerican College of Sports MedicinePhysical Inactivity • At risk if: • A combination of a sedentary job involving sitting a large part of the day • The absence of regular exercise or a recreational pursuit (accumulating 30 min or more of moderate physical activity most days of the week)

18. Signs/Symptoms of CAD • Angina • Shortness of breath at rest or with exercise • Dizzy • Nocturnal dyspnea • Edema (ankle) • Tachycardia or palpations • Heart murmur • Unusual fatigue • Claudicating (limping)

19. Pre-Participation Screening Guidelines American College of Sports Medicine ACSM Risk Stratification Categories • Low Risk (apparently healthy): = 0 -1 Risk Factor and younger • Moderate Risk:= > 2 Risk Factors OR older (>45 males; >55 female) • High Risk= Current diagnosis of Cardiac, Pulmonary, Metabolic disease (known disease) or > 1 Sign/Symptom of CAD

20. Pre-Participation Testing Guidelines American College of Sports Medicine • Pre-participation testing is recommended for: • Low Risk Mod Risk High Risk • Mod NA NA Rec • Vig NA Rec Rec • Physician Present at Exercise Tests • Sub NA NA Rec • Max NA Rec Rec

21. Pre-Participation Testing Guidelines American College of Sports Medicine Moderate Intensity • Exertional level of = 40-60% of maximal oxygen consumption • Exertional level = 3-6 METS • Brisk walking 3-4 mph (may be hard for some) • An exertional level that allows for sustained exercise for 45 minutes or more (non-competitive, well within the individuals capacity)

22. Pre-Participation Testing Guidelines American College of Sports Medicine Vigorous • Exertional level > 60% of maximal oxygen consumption • Exertional level > 6 METS • an effort great enough to cause fatigue within 20 minutes

23. Risk Factor Review Non-Modifiable • Age • Male gender • Family history Modifiable • Cigarette smoking • Hypertension • Poor cholesterol profile (High TC, LDL, Low HDL) • Diabetes • Physical Inactivity

24. Case Study • A 48-year old female desires to start an exercise program in your facility. Following an initial questionnaire and interview you find that she has no personal history of heart disease, but her father died following a heart attack at the age of 60. In addition, she has a resting BP of 145/85. Her total cholesterol is 220 with an HDL of 69. She is not obese. She currently walks 30 minutes 4 times per week, but does not strength train. According to ACSM this person is at low risk, at moderate risk, at high risk, or none of the above.

25. Case Study from previous slide • A. Undergo medical exam prior to starting a vigorous program with a physician available to supervise max exercise • B. Undergo medical exam prior to starting a vigorous program but no physician is necessary for max exercise • C. No medical exam prior to vigorous program but a physician is necessary for max exercise • D. No medical exam prior to vigorous program and no physician is necessary for max exercise.

26. Case Study • John Smith is 43. His blood pressure is 128/82, and his cholesterol is 222. He has a very stressful job and has not exercised in 7 years. John’s 70-year old mother had a heart attack last year. According to ACSM, how many positive risk factors does John have? 5, 4, 3, or 2?

27. Contraindications to Exercise • Absolute Contraindications • Recent significant change in resting ECG • Severe CAD: Unstable angina and/or acute MI • Acute CHF • Uncontrolled ventricular arrhythmia’s

28. Contraindications • Uncontrolled atrial arrhythmias (compromising cardiac function) • Third degree AV block w/o pacemaker • Suspected or known dissecting aneurysm • Aortic stenosis (narrowed) • Myocarditis or pericarditis • Thrombophlebitis or intracardiac thrombi • Recent systemic or pulmonary embolus

29. Contraindications • Acute infections • Significant emotional stress Relative Contraindications: • Hypertension: Resting DP > 110 mmHg or resting SP > 200mmHg • Moderate valvular disease • Electrolyte abnormalities • Fixed rate pace-maker

30. Contraindications • Frequent or complex ventricularectopy • Ventricular aneurysm • Uncontrolled metabolic disease (i.e., diabetes) • Chronic infectious disease • Neuromuscular, musculoskeletal, or rheumatoid disorders exacerbated by exercise • Advanced or complicated pregnancy

31. Musculoskeletal Risk Factors Tables 57.1 & 57.2 Resource Manual Intrinsic Factors • Bony alignment abnormalities • Leg length discrepancies • Muscle weakness and imbalances • Lack of flexibility • Joint laxity • Body composition

32. Musculoskeletal Risk Factors • Previous injury • Previous physical activity • Gender • Predisposing musculoskeletal disease • Warm-up, stretching exercises (???)

33. Musculoskeletal Risk Factors Extrinsic Factors • Excessive load on the body • Training “errors” • Adverse environmental conditions • Faulty equipment (I.e., worn shoes)