RISK STRATIFICATION

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RISK STRATIFICATION

Even though exercise is quite effective in the treatment of modern chronic disease, exercise has associated risk. Musculoskeletal injury is probably the most common, but the risk of heart attack and sudden death does exist. Although these risk have a low probability in cases of comprehensive evaluation, the outcome is catastrophic.

The risk associated with exercise testing:

• Sudden Death: 1/10,000 tests (0.01%)
• Heart Attack: 4/10,000 tests (0.04%)
• Complications requiring hospitalization: 10/10,000 (0.2%)
  

Risk associated with exercise training:

• Apparently Healthy Adult
  
  • Morbidity: 1/887,526 participant hours
  • Mortality: 1/1,124,200 participant hours
    
• Cardiac Patient
  
  • Morbidity: 1/34,673 participant hours
  • Mortality: 1/116,402 participant hours
    

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Levels of Risk

Low	Younger individuals Men < 45 years Women <55 years who are asymptomatic and meet no more than one risk factor for coronary heart disease.
Moderate	Older individuals Men>45 years old Women >55 years old or those who have two or more risk factors for coronary heart disease.
High	Individuals with one ore more signs/symptoms for cardiovascular disease or Individuals exhibiting cardiovascular, pulmonary or metabolic disease.

Risk factors for coronary heart disease:

Risk Factor	Definition
Family History	Myocardial infarction Coronary revascularization Sudden death before the age of 55 years old in men 65 years old in women who are first degree relatives father/mother brother/sister son/daughter
Cigarette Smoking	Current Quit within previous six months
Hypertension	Measurements must be taken on at least two separate occasions: Systolic >140 mm Hg and/or Diastolic >90 mm Hg or taking antihypertensive medications
Hypercholesterolemia	Total cholesterol > 200 mg/dl (5.2 mmol/L) HDL < 35 mg/dl (0.9 mmol/L) LDL >130 mg/dl (3.4 mmol/L) or taking lipid lowering agents
Impaired Fasting Glucose	Measurements must be taken on at least two separate occasions: Fasting Blood Glucose >100 mg/dL (5.6 mmol/L)
Obesity	Body Mass Index > 30 kg/m2 or Waist Circumference > 100 cm (39 inches)
Sedentary Lifestyle	Not participating in a regular exercise program or meeting the minimal physical activity requirement of the Surgeon General
High Serum HDL Cholesterol	HDL >60 mg/dL (1.6 mmol/L)

To establish the number of risk factors, add up the number of positive (black) risk factors and subtract the number of negative (green) risk factors. This final sum is the number of risk factors used to establish low and moderate risk.
For the high risk stratification, signs and symptoms suggestive of cardiovascular and pulmonary disease are used in conjunction with the actual diagnosis of disease. These signs and symptoms are listed below

• Pain, discomfort (or other anginal equivalent) in the chest, neck, jaw, arms, or other areas that may be due to ischemia
• Shortness of Breath
  
  • at rest
  • with mild exertion
    
• Dizziness or syncope
• Orthopenia or paroxysmal nocturnal dyspnea
• Ankle edema
• Palpitations or tachycardia
• Intermittent claudication
• Known heart murmur
• Unusual fatigue or shortness of breath with usual activities
  

If a patient presents with one or more of these symptoms or if the patient has been previously diagnosed with cardiovascular, pulmonary or metabolic disease, their risk stratification is High.

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Tools used to access information for risk stratification include: Physical Examination Laboratory Blood Reports Medical History Health Habits Body Composition Analysis Exercise Testing Different methods to obtain this information will be used in different settings. The most basic assessment for moderate physical activity in the absence of any evaluation is the Par-Q. The Par-Q was developed by the Canadian government in the 1070s as a public health movement (ParticipAction) to encourage exercise across the country. The questions from the original Par-Q are: Has your doctor ever said that you have a heart condition? Do you frequently have pains in your heart or chest? Do you often feel faint of have spells of severe dizziness? Do you take medication for blood pressure or for your heart? Has your doctor ever told you that you have a bone or joint problem such as arthritis that has been aggravated by exercise, or might be made worse with exercise? Is there a good physical reason not mentioned here why you should not follow an activity program even if you wanted to? Are you over 65 years old and not accustomed to vigorous exercise? If the participant answers NO to all the questions, they can begin a moderate exercise program. If they answer YES to any one of the questions, they should consult their physician before starting an exercise program. In 2002, the Par-Q was revised: Keep in mind, the Par-Q does not establish risk. It cannot be used for risk stratification. It does not access Overweight & obesity Cholesterol Glucose Diabetes Family History Smoking Physical Inactivity Hypertension not on meds ACSM developed a questionnaire that addressed risk factors, but does not measure them.

Decisions must be made concerning the safety of exercise testing and training based on the risk stratification. Exercise testing can be either maximal or submaximal in effort. The risk stratification helps to determine whether physician supervision of the exercise testing is required for safety. A summary of physician supervision is listed below: Type of Testing Low Risk Moderate Risk High Risk Submaximal Not Necessary Not Necessary Recommended Maximal Not Necessary Recommended Recommended Similarly, exercise training can be either moderate or vigorous. Moderate exercise is equivalent to participation in physical activity. That is, the intensity is between 40 to 60% of maximal capacity or between 3 to 6 METs. Vigorous training simulates traditional exercise more. It is used to improve cardiorespiratory endurance and has a minimum intensity of 61% of capacity. Vigorous exercise has also been defined as > 6 METs. The table below summarizes the need for a medical examination and exercise testing prior to participation in exercise training. Type of Training Low Risk Moderate Risk High Risk Moderate Not Necessary Not Necessary Recommended Vigorous Not Necessary Recommended Recommended The American College of Sports Medicine is not the only body to develop Risk Stratification systems for safety in exercise. Other professional organizations include: American Heart Association American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) American College of Cardiology

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