NEW PREPARTICIPATION HEALTH

SCREENING RECOMMENDATIONS
What Exercise Professionals Need to Know
by Meir Magal, Ph.D., ACSM CEP, FACSM and Deborah Riebe, Ph.D., ACSM EP-C, FACSM

Learning Objectives
From this article, the readers should
understand the following:
The rationale for updating the
ACSM exercise preparticipation
screening procedures
How to use the updated ACSM
exercise preparticipation screening recommendations
How to use the newly developed
exercise preparticipation health
screening questionnaire for exercise professionals tool

INTRODUCTION

n important role of the exercise professional is to ensure the safety of their

clients and patients. The American College of Sports Medicine (ACSM)
recommends that individuals interested in beginning or progressing in an
exercise program undergo exercise preparticipation health screening.
The purpose of this process is to identify individuals who may be at elevated risk for exercise-related sudden cardiac death (SCD) and/or acute myocardial infarction (AMI). Vigorous-intensity exercise has a small risk of an acute cardiovascular
(CV) event; therefore, identifying susceptible individuals is important.
ACSM recently held a scientific round table to evaluate and refine the exercise
preparticipation health screening procedures. Experts in the areas of risk assessment, preventive cardiology, general cardiology, public health, exercise physiology, and geriatrics as
well as practitioners from the fields of medicine, clinical exercise physiology, and health
fitness/prevention reviewed and discussed the scientific literature associated with the risk
of exercise-related adverse CV events. The expert panel proposed new evidence-informed

Key words: Exercise Prescription,

Inactivity, Exercise Intensity, Medical
Clearance, Cardiovascular Disease

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May/June 2016

exercise preparticipation health screening recommendations

procedures, which will be presented.
Although the goals of exercise preparticipation health screening remain the same, the new procedures represent a significant
departure from the current edition of ACSM's Guidelines for
Exercise Testing and Prescription (15). This article summarizes the
changes in exercise preparticipation screening procedures, presents the rationale for the changes, and provides exercise professionals guidance in applying the new recommendations. The
new ACSM recommendations are not a replacement for sound
clinical judgment, and decisions about referral to a health care
provider for medical clearance before the initiation of an exercise program should continue to be made on an individual
basis (9).

WHY CHANGE THE EXISTING EXERCISE

PREPARTICIPATION HEALTH SCREENING PROCESS?
Exercise is safe for most people. It is well known that the transient risks
of SCD and AMI are substantially higher during acute vigorous
physical exertion as compared with rest, especially in habitually
sedentary people with known or occult (i.e., hidden) CV disease
(CVD) who engage in unaccustomed strenuous physical exertion. However, the absolute risk of these events is extremely
low. Both prospective and retrospective studies demonstrate
the rarity of CV events during exercise (Table 1).
Cardiovascular disease risk factors do not predict adverse CV events.
There is a high prevalence of CVD risk factors among adults,
yet exercise-related SCD and AMI are extremely rare. For example, 65 million U.S. adults have hypertension and 71 million
adults have high low-density lipoprotein cholesterol levels (3,12),
yet only 600,000 people die from heart disease each year, and
only a small fraction of those are caused by exercise-associated
SCD and AMI (4). Therefore, using CVD risk factors to riskidentify those susceptible to exercise-associated SCD or AMI is
unlikely to be effective in achieving its intended purpose. It is important to note that identifying and controlling CVD risk factors
continue to be an important objective of overall CV and metabolic disease prevention and management. Therefore, exercise
professionals are encouraged to complete a CVD risk factor
assessment with their patients/clients even though it is no longer
included in the exercise preparticipation health screening process as a determinant of medical clearance for exercise.

Current guidelines may be too conservative. The existing exercise

preparticipation health screening may be overly conservative
primarily because of the high prevalence of CVD risk factors.
A recent study found that 95% of men and women older than
40 years would be advised to consult a physician before exercise
based on the previous risk factor-based exercise preparticipation health screening process (19).
Prescreening may be a barrier to physical activity. Unnecessary referral to a health care provider to potentially identify underlying
coronary artery disease may be a barrier to becoming physically
active (15). Further diagnostic testing may lead to a high rate of
false-positive exercise test responses in some populations, necessitating medical follow-up and additional noninvasive/invasive
studies when they are not needed. Such studies can place unnecessary financial and other burdens on the individual and the
health care system (6).
Warning signs and symptoms. Exercise-related CV events often
are preceded by warning signs or symptoms (16).
There may be more effective ways to prevent exercise-related CV events.
Exercise-related CV events more likely may be reduced by careful
attention to the exercise prescription. The exercise prescription
should incorporate a progressive transitional phase (i.e., 2 to
3 months) during which the duration and intensity of exercise are
increased gradually and should include an appropriate warm-up
and cool-down. Clients should be familiarized with the warning
signs/symptoms of CVD and should be counseled to start low
and go slow; that is, to avoid unaccustomed vigorous-to-nearmaximal-intensity physical activity (Table 2).

WHAT IS NEW?
The current preparticipation health screening recommendations outlined in the ninth edition of ACSM's Guidelines for Exercise
Testing and Prescription require the exercise professional to 1) complete a CVD risk factor profile; 2) determine if the client/patient
has known CV, pulmonary, and/or metabolic diseases; and
3) identify major signs or symptoms suggestive of CV, pulmonary,
and/or metabolic diseases. Using this information, the client/
patient is classified as low, moderate, or high risk (13). Based on
the risk classification and the intensity of the intended exercise
training or exercise test, a decision is made concerning 1) the need
for a medical examination, 2) the need for an exercise test, and
3) the need for a physician to be present during the exercise test (13).

TABLE 1: The Risk for Adverse CV Event During a Bout of Exercise

Study or Population

Risk of Adverse CV Event

Nurses' Health Study (1)

SCD occurs every 1.5 million episodes of vigorous physical exertion

Physicians' Health study (18)

SCD occurs every 36.5 million hours of moderate-to-vigorous exertion in women

Joggers in Rhode Island (17)

1 death per 396,000 hours of jogging

YMCA participants (10)

1 death per 2,897,057 person-hours

Marathon and half-marathon

runners (9)

1 AMI incident per 184,000 runners and 1 SCD incident per 256,000 runners, which translate to 0.20
AMIs and 0.14 SCDs per 100,000 estimated runner-hours

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ACSM'S UPDATED HEALTH SCREENING

The new preparticipation health screening process differs in

that it does not include risk factor analysis or risk level classification and makes recommendations for physician clearance rather
than specific recommendations for a medical examination or
exercise test. Rather, it is based on 1) the individuals current
level of structured physical activity; 2) the presence of major signs
or symptoms suggestive of CV, metabolic, or renal diseases; and
3) the desired exercise intensity (Figure 1). For a downloadable
PDF, go to http://links.lww.com/FIT/A31.
The first part of the new screening process is to determine the
level of participation in habitual exercise or a structured physical
activity program. Several reasons have led to the decision of
placing habitual exercise or structured physical activity program
in a key role in the new exercise preparticipation screening recommendations. First, independent of any other risk factor, physically active individuals are at a lower risk for any cardiac event
when compared with physically inactive individuals (7). Second,
the relative risk of adverse cardiac events during exercise is inversely related to one's usual level of physical activity (5,11).
Third, participation in regular physical activity reduces the risk
of CVD-related events by half during a given 24-hour period
(2,14). Lastly, an inverse relationship is apparent between the
number of exercise sessions per week and the risk of experiencing CV-related events during these exercise sessions (5).
The recognition of known CV, metabolic, and renal diseases
and the presence of major signs or symptoms suggestive of these
diseases remains an important part of the preparticipation screening
recommendations. However, individuals with pulmonary disease

are no longer automatically required to receive medical clearance. Although CVD and pulmonary diseases share smoking
as a common risk factor, the presence of pulmonary disease does
not increase the risk of experiencing an adverse CVD event per se
(15). In fact, the increased risk of an adverse CVD event is associated with the inactive and sedentary lifestyle of many individuals with pulmonary disease (8).
Finally, the recommendation for medical examination and/or
diagnostic exercise test before the commencement of an exercise
program was replaced with a recommendation for medical clearance (Figure 1). The term medical clearance was chosen to suggest
that, after referral, the health care provider is in the best position
to decide what the next step is in respect to the evaluation of a
patient before approving the initiation of any exercise program
(15). It is important to point out that although there are some
substantial changes to the recommendations, the objectives of
the process have remained the same as stated in the current
guidelines (13):
1. To identify those who should receive medical clearance
before starting a new program or increasing the frequency,
intensity, and/or volume of an existing exercise program.
2. To identify those who present with CV, metabolic,
and/or renal diseases and will benefit from participating
in a medically supervised exercise program.
3. To identify those with CV, metabolic, and/or renal diseases who must wait until their medical condition(s) have
improved to proceed with an exercise program.

HOW TO USE THE UPDATED EXERCISE

PREPARTICIPATION HEALTH SCREENING PROCESS?
As previously mentioned, the new exercise preparticipation
health screening process is based on current levels of structured
physical activity; the presence of major signs or symptoms suggestive of CV, metabolic, or renal diseases; and the desired exercise
intensity. After the determination of the physical activity participation
(defined as performing planned structured physical activity for at
least 30 minutes at moderate intensity on at least 3 days/week for
at least the last 3 months), a participant is placed into the no
branch (left) or the yes branch (right) (Figure 1).
For individuals who are currently active:
1. If asymptomatic without known CV, metabolic, or renal
diseases, one may continue the exercise program and may
progress gradually using published ACSM guidelines (13).

TABLE 2: Keeping Participants Safe During Exercise Tips for the Exercise Professional
Design an appropriate and effective program using the FITT principles of exercise prescription.
Include an adequate warm-up and cool-down in the exercise prescription and confirm that the client/patient does not skip this step.
Incorporate a 2- to 3-month transitional phase where the intensity and duration of exercise are increased gradually.
Educate your client/patient about the warning signs and symptoms of CVD.
Encourage sedentary individuals to start low and go slow. Remind them to avoid unaccustomed vigorous physical activity.
FITT indicates frequency, intensity, time, and type.

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May/June 2016

Figure 1. The American College of Sports Medicine preparticipation screening algorithm. (Reprinted from: Riebe D,
et al. Updating ACSM's recommendations for exercise preparticipation health screening. Med. Sci. Sports Exerc. 2015;
47(11):24732479. Copyright 2015 Lippincott, Williams & Wilkins. Used with permission.)

2. If asymptomatic with known CV, metabolic, or renal diseases, one may continue the exercise program
as long as one remains symptom free and as long
as medical clearance was given within the last
12 months.
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3. If symptomatic with or without known CV, metabolic,

or renal diseases, one should discontinue the exercise
program and seek medical clearance.
For individuals who are currently inactive:
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25

ACSM'S UPDATED HEALTH SCREENING

1. If asymptomatic without known CV, metabolic, or renal
diseases, one may engage in a light- to moderate-intensity
exercise program and may progress gradually using published ACSM guidelines (13).
2. If asymptomatic with known CV, metabolic, or renal diseases, one should discontinue the exercise program and
seek medical clearance.
3. If symptomatic with or without known CV, metabolic,
or renal diseases, one should discontinue the exercise
program and seek medical clearance.

To further simplify the exercise preparticipation screening

process for the exercise professional, we have included a newly
developed screening checklist (Figure 2). For a downloadable
PDF, go to http://links.lww.com/FIT/A32. The checklist includes three easy-to-follow steps that may indicate to the exercise
professional how to proceed with one's client (i.e., allow client to
start an exercise program, participate in an exercise program,
or refer client to a health care provider). To use the checklist,
the exercise professional must determine if the client 1) has
any signs or symptoms of CV, metabolic, or renal diseases;

Figure 2. Exercise preparticipation health screening questionnaire for exercise professionals.

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May/June 2016

13. Pescatello LS. American College of Sports Medicine. ACSM's Guidelines for
Exercise Testing and Prescription. 9th ed. Philadelphia (PA): Wolters
Kluwer/Lippincott Williams & Wilkins Health; 2014. xxiv, 456 p.
14. Powell KE, Thompson PD, Caspersen CJ, Kendrick JS. Physical activity and the
incidence of coronary heart disease. Annu Rev Public Health. 1987;8:25387.
15. Riebe D, Franklin BA, Thompson PD, et al. Updating ACSM's recommendations for
exercise preparticipation health screening. Med Sci Sports Exerc. 2015;47(11):
24739.
16. Thompson PD, Franklin BA, Balady GJ, et al. Exercise and acute cardiovascular
events placing the risks into perspective: a scientific statement from the
American Heart Association Council on Nutrition, Physical Activity, and
Metabolism and the Council on Clinical Cardiology. Circulation. 2007;115(17):
235868.
17. Thompson PD, Funk EJ, Carleton RA, Sturner WQ. Incidence of death during
jogging in Rhode Island from 1975 through 1980. JAMA. 1982;247(18):25358.
18. Whang W, Manson JE, Hu FB, et al. Physical exertion, exercise, and sudden
cardiac death in women. JAMA. 2006;295(12):1399403.

2) is physically active; and 3) has a known CV, metabolic, or renal disease. The information gathered with the checklist will
guide the exercise professional in making a decision about the
need for medical clearance.

19. Whitfield GP, Pettee Gabriel KK, Rahbar MH, Kohl HW III. Application of the
American Heart Association/American College of Sports Medicine Adult
Preparticipation Screening Checklist to a nationally representative sample of US
adults aged >=40 years from the National Health and Nutrition Examination
Survey 2001 to 2004. Circulation. 2014;129(10):111320.

Acknowledgment

Disclosure: The authors declare no conflict of interest and do not have any
financial disclosures.

The authors thank Drs. Gary Liguori and Geoffrey Whitfield

for their insightful comments and suggestions concerning the
newly developed Figure 2.
1. Albert CM, Mittleman MA, Chae CU, Lee IM, Hennekens CH, Manson JE.
Triggering of sudden death from cardiac causes by vigorous exertion. N Engl J
Med. 2000;343(19):135561.
2. Berlin JA, Colditz GA. A meta-analysis of physical activity in the prevention of
coronary heart disease. Am J Epidemiol. 1990;132(4):61228.
3. Centers for Disease Control and Prevention (CDC). Adult participation in aerobic
and muscle-strengthening physical activities United States, 2011. MMWR
Morb Mortal Wkly Rep. 2013;62(17):32630.
4. Centers for Disease Control and Prevention Web site [Internet]. Atlanta (GA):
Centers for Disease Control and Prevention; [12/1/15]. Available from:
http://www.cdc.gov/heartdisease/facts.htm.
5. Dahabreh IJ, Paulus JK. Association of episodic physical and sexual activity with
triggering of acute cardiac events: systematic review and meta-analysis. JAMA.
2011;305(12):122533.
6. Franklin BA. Preventing exercise-related cardiovascular events: is a medical
examination more urgent for physical activity or inactivity? Circulation. 2014;
129(10):10814.

Meir Magal, Ph.D., ACSM CEP, FACSM, is

a program coordinator and associate professor of Exercise Science at North Carolina Wesleyan College. He
currently is serving as the chair of the International Subcommittee and as a member of the Executive Council of
ACSM's Committee on Certification and Registry
Boards.

Deborah Riebe, Ph.D., ACSM EP-C, FACSM,

is a professor and chair of the Department of Kinesiology
at the University of Rhode Island. She currently serves
on ACSM's Board of Trustees and Administrative
Council.

7. Franklin BA, McCullough PA. Cardiorespiratory fitness: an independent and

additive marker of risk stratification and health outcomes. Mayo Clin Proc. 2009;
84(9):7769.
8. Hill K, Gardiner PA, Cavalheri V, Jenkins SC, Healy GN. Physical activity and
sedentary behaviour: applying lessons to chronic obstructive pulmonary disease.
Intern Med J. 2015;45(5):47482.
9. Kim JH, Malhotra R, Chiampas G, et al. Cardiac arrest during long-distance
running races. N Engl J Med. 2012;366(2):13040.
10. Malinow M, McGarry D, Kuehl K. Is exercise testing indicated for asymptomatic
active people? J Cardiac Rehabil. 1984;4(9):37680.
11. Mittleman MA, Maclure M, Tofler GH, Sherwood JB, Goldberg RJ, Muller JE.
Triggering of acute myocardial infarction by heavy physical exertion. Protection
against triggering by regular exertion. Determinants of Myocardial Infarction
Onset Study Investigators. N Engl J Med. 1993;329(23):167783.
12. Nwankwo T, Yoon SS, Burt V, Gu Q. Hypertension among adults in the United
States: National Health and Nutrition Examination Survey, 20112012. NCHS
Data Brief. 2013;(133):18.

Volume 20 | Number 3

BRIDGING THE GAP

The benefits of engaging and maintaining habitual
physical activity and exercise are well known.
The updated ACSM preparticipation health screening
recommendations are based on the available scientific
evidence and are designed to remove barriers to
exercise by eliminating the need for unnecessary
health care provider referrals. This supports the public
health message that physical activity is important for
all individuals.

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