The American College of Sports Medicine (ACSM)’s newest edition of its Guidelines for Exercise Testing and Prescription the Ninth Edition, edited by UConn Board of Trustees Distinguished Professor of Kinesiology Linda Pescatello, removes barriers that often delay or prevent healthy individuals from starting beneficial exercise programs.
ACSM’s Guidelines for Exercise Testing and Prescription is based on the most current evidence in the field, including ACSM position and statement stands, and the book is the most widely circulated set of exercise guidelines in the world, the “international gold standard,” for all professionals conducting exercise testing or exercise programs, said Dr. Pescatello, who served as senior editor of the ninth edition, published during the spring semester, and associate editor of the eighth edition, published in 2009.
Previous editions of the ACSM’s Guidelines recommended a medical examination and physician-administered exercise testing, or stress testing, as part of pre-participation health screening prior to initiation of vigorous-intensity exercise in individuals at moderate risk of cardiovascular disease to identify those at risk for a sudden adverse cardiac event during exercise. The new edition of the Guidelines, presented by Dr. Pescatello at the ACSM’s Health Fitness Summit in Las Vegas this March and ACSM’s Annual Conference in Indianapolis earlier this month, still recommends both a medical exam and physician-administered stress testing for individuals at high risk of, or with known, cardiovascular disease before they begin either a moderate or vigorous-intensity exercise program, but the Guidelines no longer recommend these steps for individuals at moderate risk before they start a progressive exercise regimen and no longer recommend stress testing for the same group before starting vigorous-intensity exercise.
“The updated guidelines for pre-participation health screening remove unnecessary and unproven barriers to starting an exercise program and reinforce the public health message that the benefits of exercise far outweigh the risks,” said Dr. Pescatello, a principal investigator at UConn’s Center for Health, Intervention, and Prevention (CHIP). “At the same time, the guidelines place a stronger need on identifying those clients with known disease because they are at the highest risk for an exercise-related cardiac event.”
Previous editions of the Guidelines considered individuals at increased risk for cardiovascular disease based on age (men age 45 and older and women age 55 and older automatically were considered at increased risk), their number of risk factors, absence or presence of symptoms, and known disease. The updated Guidelines classify individuals as low-, moderate-, or high-risk based on their number of risk factors (including age), the absence or presence of symptoms, and known disease. An individual without symptoms and with less than two risk factors is considered low-risk while an individual without symptoms with two or more risk factors is considered moderate-risk. The presence of symptoms of or known cardiovascular, pulmonary, renal, or metabolic disease qualifies an individual as high risk.
In place of previous emphasis on medical evaluation, the new pre-participation health screening guidelines place a greater emphasis on self-guided screening methods, encouraging all individuals wishing to initiate a physical activity program to complete a health risk appraisal questionnaire at minimum, Dr. Pescatello said. The need and degree of follow-up required then can be guided by the responses to the questionnaire, she said.
“There are multiple considerations that have prompted these different points of emphasis,” Dr. Pescatello explained. “The risk of a cardiovascular event is increased during vigorous-intensity exercise relative to rest, but the absolute risk of a cardiac event is low in healthy individuals. Recommending a medical examination and stress test as part of the pre-participation health screening process for all people at moderate to high risk prior to initiating a light- to moderate-intensity exercise program implies that being physically active confers greater risk than a sedentary lifestyle.”
Hartford Hospital cardiologist Dr. Paul Thompson, a research collaborator of Dr. Pescatello since 1998 who wrote his first article on the cardiac complications of exercise in the Journal of the American Medical Association (JAMA) in 1979, served as associate editor of the new Guidelines and wrote the introductory chapter for the book emphasizing the safety and benefits of exercise. He also authored what Dr. Pescatello described as the “long overdue” second chapter, which contains the new pre-participation health screening recommendations.
Dr. Thompson said there is increasing recognition that stress testing is a poor predictor of acute CVD events, such as heart attacks and sudden death, in asymptomatic individuals, probably because such testing detects blood flow-limiting coronary lesions, whereas sudden cardiac death and acute myocardial infarction are produced usually by the rapid progression of a previously non-obstructive lesion.
In the introductory chapter, Dr. Thompson also wrote: “A large body of scientific evidence supports the role of physical activity in delaying premature mortality and reducing the risks of many chronic diseases and health conditions. There is also clear evidence for a dose-response relationship between physical activity and health.”
Dr. Pescatello said other new features of the ninth edition of the Guidelines include a new chapter about proven theory-based behavioral methods to increase adherence to exercise programs, more specific information about working with special populations, such as those who have had bariatric surgery or who have multiple chronic diseases and health conditions, and a new automated reference system developed by UConn Medical Librarian Jill Livingston.
For the first time for the ninth edition, Dr. Pescatello also invited a clinical pharmacist – UConn Assistant Clinical Professor of Pharmacy Practice and CHIP affiliate, Thomas Buckley – to prepare the appendix on commonly encountered medications among people that exercise.
Dr. Pescatello’s work on the ninth edition of the Guidelines began almost as soon as her work on the eighth edition ended.
“It is a professional honor to be selected as editor of the ACSM’s Guidelines for Exercise Testing and Prescription because of the significant impact they have on the work that we do in our field,” she said, “and it is a labor of love.”