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Pre-screening - Health Screening and Risk Stratification...

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Unformatted text preview: Health Screening and Risk Stratification PrePre-Screening and Risk Stratification Chapter 2 and 3 ACSM What is involved in the prepreprocess screening process? The The Basic Goal – To determine if it is safe for an individual to start an exercise program what exercise program, what type type of exercise testing is appropriate, and what medical supervision is necessary. ACSM, ACSM, AHA, AACVPR have set specific guidelines concerning pre-participation prescreening and primary and secondary stratification stratification Health Health Concerns Contraindications Contraindications Increased Increased Risk Medical Medical supervision or other special needs What is the process? 1. If in a clinical setting, obtain informed consent. 2. A form of medical and health history 3. What goals for activity does the person have? (this is important !!!) !!!) 4. Risk Stratify the client. 5. Decided whether it is recommended to do a physical exam, exercise test the person, AND what type of test is appropriate. 6. Decide if your facility can test the person by….. 1 PrePre-participation Screening Informed Informed Consent (pg 53 example) PARPAR-Q* - minimal standard Physical Physical Exam findings Lung sounds Lung sounds Heart Heart sounds Laboratory Laboratory Tests Blood Blood Blood Blood pressure Pulmonary Pulmonary Function FIGURE 2-1, ACSM Guidelines 2 PrePre-participation Screening Medical Medical History Diagnoses Diagnoses Hospitalizations/ Hospitalizations/ Surgery Medications Medications (action, dose) Taking meds regularly Taking meds regularly Family Family Hx Risk Risk Factors* Current Current Physical Activity Hx Previous Previous exercise test findings Frequency, Frequency, Type, signs and symptoms (SxS) – (Box 2-1) 2Veteran’s Veteran’s Specific Activity Questionnaire Veterans Specific Activity Questionnaire (VSAQ) PrePre-participation Screening (con’t) Risk Risk Factors (Table 2-1) 2Family Family History Cigarette Cigarette Smoking Hypertension Hypertension Hypercholesterolemia Hypercholesterolemia Impaired Impaired fasting glucose Obesity Obesity Sedentary Sedentary lifestyle Negative Negative Risk Factor High High serum HDL Physical Activity Screening - Symptoms Which Which of the following SxS do you have with exertion? (BOX 2-1) 2Chest Chest discomfort or pain or in surrounding area Type, Type, when, severity Shortness Shortness of breath (SOB) Dizziness Dizziness or syncope Palpitations Palpitations or tachycardia Claudication Claudication (pain in legs) 3 Angina Physical Activity Screening - Symptoms Orthopnea Orthopnea or paroxysmal nocturnal dyspnea Known Known heart murmur Unusual Unusual fatigue or shortness of breath with usual activities Types of Angina and Associated Pathophysiology Demand Demand > Supply Diagnosis Diagnosis (DX) – stress testing, angiography Treatment Treatment – Pharmacologic Pharmacologic Secondary Secondary Risk Reduction Exercise Exercise – based on symptomology Initial Risk Stratification (ACSM, Box 2-2) Risk (ACSM, Low Low Typical Typical Angina – evoked by exertion, emotions, cold/heat exposure, meals, and sexual intercourse; relieved by rest or nitroglycerin relieved by rest or nitroglycerin Moderate Moderate Stable Stable Angina – reproducible and predictable in onset Atypical Atypical Angina – no relationship to exertion Unstable Unstable Angina – new onset of typical angina, increasing in intensity or occurs at rest Variant Variant (Prinzmetal’s angina) - High High 4 Secondary Risk Stratification (for (for those who already have a medical diagnoses) AACVPR AACVPR Low Low risk – stable, functional capacity > 6 METs, EF > 50%, symptoms may occur at high MET levels Moderate – EF = 40 – 50%, reduced functional EF 40 50% capacity (5capacity (5-6 METs) with SxS High High – unstable, poor ventricular function, SxS below 5 METs Need a physical exam and exercise test? What type of test is recommended? AHA AHA Class Class A, B, C, and D Are there any known medical conditions that might cause problems with exercise or exercise testing? Stage 1: Known Diseases Yes -Medical checkup needed -Doctor needed at maximal test -Doctor needed at submax test No Are there any signs or symptoms of underlying cardiopulmonary disease, even if it hasn't been diagnosed? Are there any risk factors that might mean this person is presisposed to cardiovascular disease? Stage 2: Signs and Symptoms of Cardiopulmunary Disease Yes Vigorous Exercise -Medical checkup needed -Doctor needed at maximal test -No doctor needed at submax test No Stage 3: Cardiac Risk Factors Yes Stage 5: Exercise Choice No Is this person at or above the cutoff age limits: 44 for men and 54 for women? Stage 4: Age Risk Yes No Moderate Exercise -No medical checkup needed -Doctor needed at maximal test -No doctor needed at submax test -No medical checkup needed prior to exercise training -No medical supervision for maximal or submaximal exercise test 5 Indications for Exercise Testing1. SxS SxS Exercise Exercise induced SxS Angina Angina Old or new ECG abnormalities 2. Prognosis 3. Exercise Capacity, Prescription Evaluate Rx Outcomes Use Use to predict mortality 4. Contraindications to Exercise Testing Diagnosis Do Do the risks of exercise testing outoutweigh indications? Absolute Absolute – under no circumstances* should should the test be performed Relative Relative – must weigh with indications for testing to determine outcome (Froelicher. Handbook of Exercise Testing.1996 Contraindications for Exercise Testing Absolute (KNOW!!!) (Box 3-5) 3Recent Recent MI, acute event, change in resting ECG Unstable Unstable Angina Uncontrolled Uncontrolled arrythmia Severe Severe symptomatic aortic stenosis Uncontrolled Uncontrolled symptomatic heart failure Acute Acute pulmonary embolus or pulmonary infarction Acute Acute myocarditis or pericarditis Suspected Suspected or known dissecting aneurysm Acute Acute infections Contraindications for Exercise Testing Relative (Be aware of) Left Left main coronary stenosis Moderate Moderate valvular disease Electrolyte Electrolyte abnormalities Arterial Arterial Hypertension Tach or bradarrhythmias Tac Hypertropic Hypertropic cardiomyopathy Orthopedic Orthopedic conditions which limit mobility HighHigh-degree AV block Slide 21 Ventricular Ventricular Aneurysm Uncontrolled Uncontrolled metabolic disease Chronic Chronic infectious disease 6 Testing Facility (Emergency Procedures) Normal High degree heart block Need Need appropriate equipment (AHA) Defibrillator? Defibrillator? Airway Airway / oxygen Drugs Dru Phone Phone Need Need appropriate staff High degree Heart block Physician Physician EMT/nurse EMT/nurse Exercise Exercise SpecialistSM or equivalent experience Contraindications for Exercise Testing Relative (Know!!) ... Case Study #1 – Should we do GXT and what type? Jerry Jerry Attrik 67 67 yr old Caucasian male, recently retired Not Not active Wt Wt = 217 lbs Ht = 68 in 125 cm waist circumference Medications Medications - Atenolol ( beta blocker), Ibuprofen Heart Catheterization 2 years ago: results unknown Family Family Hx – Father diagnosed with CAD Disease at Age 40 Resting Resting BP – 128/88 Total Total Cholesterol 230 mg/dL – no other information on blood work is available Reports Reports being tense and overstressed often Reports Reports frequent episodes of chest tightness while mowing the lawn. Case Case Study #2 – Does she need a physical exam and exercise test? Moram Moram Ovement 25 25 yr old Hispanic female Wt Wt = 157 lbs Ht = 62 in 30 percent body fat She She is going to join LA Fitness and go to their aerobics classes. classes. She is a friend of yours and heard that you were an exercise science major. She wants advice on getting started and losing weight. She has never participated in a regular exercise program of any type. She currently smokes a few cigarettes a day. Her resting blood pressure is 138/86. Her blood parameters are all below risk level and she has no family history of CAD. 7 ...
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