American College of Sports Medicine

Major Coronary Risk Factors& Pre-Participation Guidelines

___________________As Established by the

American College of Sports Medicine

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.

The Realm of Risk Factor Modification

Primary Prevention - intervention prior to the onset of CAD

Secondary Prevention - intervention after the onset of CAD

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).

The Purposes for The Purposes for Pre-Participation Health Pre-Participation Health

ScreeningsScreenings Review of Review of

ACSM GuidelinesACSM Guidelines

Health Screening DevicesBy order of cost and complexity

Self administered health questionnairePar QAnalysis of CAD Risk Profile Physical exam by a physicianBasic diagnostic Exercise Testing (GXT)

Advanced diagnostic exercise testing (Nuclear stress,

Stress Echo, Pharmacological Stress)

Risk Factors for CAD American College of Sports MedicinePositive Risk Factors

Age Family History Cigarette Smoking Hypertension Hypercholesterolemia Diabetes Mellitus Sedentary Lifestyle/Activity

Negative Risk FactorsHigh Serum HDL Cholesterol

Risk Factors for CAD American College of Sports Medicine

Table 2-1 Page 24 in Guidelines or Page 19 in Heyward.

Risk Factors

Count the number of positive risk factors and subtract the number of negative risk factors

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.

Family HistoryFamily History


At risk if,

Current use is present. Residual effects may be manifest even if

smoking has stopped

Removal of Risk (?)Removal of Risk (?)Cessation for > 2-6 monthsCessation for > 2-6 months


Cigarette/Cigar Smoking

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)


Blood Pressure

Blood Pressure:Blood Pressure:

SystolicSystolic DiastolicDiastolic

OptimalOptimal <120<120 <80<80

NormalNormal 120-129120-129 80-8480-84

High NormalHigh Normal 130-139130-139 85-8985-89

Hypertension:Hypertension:

Stage 1 Stage 1 140-159140-159 90-9990-99

Stage 2 Stage 2 160-179160-179 100-109100-109

Stage 3 Stage 3 >>180180 >>110110


Hypercholesterolemia (Positive Risk)

On lipid lowering medsIf 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


Hypercholesterolemia (Negative Risk)

Lipoprotein profile must be available.

Subtract one risk factor if HDL cholesterol is > 60 mg/dL


Diabetes MellitusAt 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

Risk Factors

Other risk factors:Other risk factors:Obesity (AHA) BMI>30 or waist of >100 Obesity (AHA) BMI>30 or waist of >100

cm for men and >88 for womencm for men and >88 for womenUse your best judgement due to the controversyUse your best judgement due to the controversy


Physical InactivityAt 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)

Signs/Symptoms of CAD

AnginaShortness of breath at rest or with exerciseDizzyNocturnal dyspneaEdema (ankle)Tachycardia or palpationsHeart murmurUnusual fatigueClaudicating (limping)

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

Pre-Participation Screening GuidelinesPre-Participation Screening Guidelines American College of Sports Medicine American College of Sports Medicine

ACSM Risk Stratification CategoriesACSM Risk Stratification Categories

Pre-Participation Testing GuidelinesPre-Participation Testing Guidelines American College of Sports MedicineAmerican College of Sports Medicine

Pre-participation testing is recommended for:

– Low Risk Mod Risk High Risk

Mod NA NA RecVig NA Rec RecPhysician Present at Exercise TestsSub NA NA RecMax NA Rec Rec


Moderate IntensityModerate IntensityExertional level of = 40-60% of maximal oxygen consumptionExertional level = 3-6 METSBrisk 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)


Vigorous Vigorous

Exertional level > 60% of maximal oxygen consumption

Exertional level > 6 METSan effort great enough to cause fatigue

within 20 minutes

Risk Factor ReviewRisk Factor ReviewNon-ModifiableNon-ModifiableAgeAgeMale genderMale genderFamily historyFamily history

ModifiableModifiableCigarette smokingCigarette smokingHypertensionHypertensionPoor cholesterol profile Poor cholesterol profile (High TC, LDL, Low HDL)(High TC, LDL, Low HDL)

DiabetesDiabetesPhysical InactivityPhysical Inactivity

Case StudyA 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.

Case Study from previous slideA. 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.

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?

Contraindications to Exercise

Absolute ContraindicationsAbsolute Contraindications Recent significant change in resting ECGRecent significant change in resting ECG Severe CAD: Unstable angina and/or acute MISevere CAD: Unstable angina and/or acute MI Acute CHFAcute CHF Uncontrolled ventricular arrhythmia’sUncontrolled ventricular arrhythmia’s

ContraindicationsContraindications Uncontrolled atrial arrhythmias (compromising Uncontrolled atrial arrhythmias (compromising

cardiac function)cardiac function) Third degree AV block w/o pacemakerThird degree AV block w/o pacemaker Suspected or known dissecting aneurysmSuspected or known dissecting aneurysm Aortic stenosis (narrowed)Aortic stenosis (narrowed) Myocarditis or pericarditisMyocarditis or pericarditis Thrombophlebitis or intracardiac thrombiThrombophlebitis or intracardiac thrombi Recent systemic or pulmonary embolusRecent systemic or pulmonary embolus

ContraindicationsContraindications

Acute infectionsAcute infections Significant emotional stressSignificant emotional stress

Relative ContraindicationsRelative Contraindications:: Hypertension: Resting DP > 110 mmHg or resting SP Hypertension: Resting DP > 110 mmHg or resting SP

> 200mmHg> 200mmHg Moderate valvular diseaseModerate valvular disease Electrolyte abnormalitiesElectrolyte abnormalities Fixed rate pace-makerFixed rate pace-maker

ContraindicationsContraindications Frequent or complex ventricularFrequent or complex ventricular ectopyectopy Ventricular aneurysmVentricular aneurysm Uncontrolled metabolic disease (i.e., diabetes)Uncontrolled metabolic disease (i.e., diabetes) Chronic infectious diseaseChronic infectious disease Neuromuscular, musculoskeletal, or rheumatoid Neuromuscular, musculoskeletal, or rheumatoid

disorders exacerbated by exercisedisorders exacerbated by exercise Advanced or complicated pregnancyAdvanced or complicated pregnancy

Musculoskeletal Risk FactorsMusculoskeletal Risk Factors

Tables 57.1 & 57.2 Resource ManualTables 57.1 & 57.2 Resource Manual

Intrinsic FactorsIntrinsic Factors Bony alignment abnormalitiesBony alignment abnormalities Leg length discrepanciesLeg length discrepancies Muscle weakness and imbalancesMuscle weakness and imbalances Lack of flexibilityLack of flexibility Joint laxityJoint laxity Body compositionBody composition


Previous injuryPrevious injuryPrevious physical activityPrevious physical activityGenderGenderPredisposing musculoskeletal diseasePredisposing musculoskeletal diseaseWarm-up, stretching exercises (???)Warm-up, stretching exercises (???)


Extrinsic FactorsExtrinsic Factors

Excessive load on the bodyExcessive load on the bodyTraining “errors”Training “errors”Adverse environmental conditionsAdverse environmental conditionsFaulty equipment (I.e., worn shoes)Faulty equipment (I.e., worn shoes)

American College of Sports Medicine

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