A Call to Action to Reduce the Need for a Medical Evaluation Prior to Exercise

The purpose of the American College of Sports Medicine's (ACSM) exercise preparticipation health screening recommendations is to identify individuals who may be at elevated risk for an exercise-related sudden cardiovascular event (1,2). The present ACSM recommendations were revamped in 2015 to reduce unnecessary barriers to adopting and maintaining a regular exercise program and/or a physically active lifestyle and reinforce the public health message that regular physical activity (PA) is important for all. The rationale for doing so was due to growing evidence: exercise is safe, PA has many health benefits; exercise-related cardiovascular events are rare and often preceded by warning signs and symptoms, and the cardiovascular risks associated with exercise wane as individuals become more physically active and/or fit (1). The ACSM recommendations consider three factors when determining if there is a need for medical clearance prior to exercise: 1) the individual's current PA level, 2) presence of signs or symptoms and/or known cardiovascular, metabolic, or renal disease, and 3) exercise intensity (see Supplemental Digital Content, Figure, https://links.lww.com/CSMR/A159) (1,2). For regularly physically active individuals: who are asymptomatic without known cardiovascular, metabolic (i.e., diabetes mellitus, DM), or renal disease, they may continue their usual exercise program and gradually progress as tolerated following the ACSM exercise prescription (ExRx) guidelines; who are asymptomatic with known cardiovascular, metabolic, or renal disease, whose healthcare provider has cleared them to exercise within the last 12 months, do not need to see their healthcare provider to continue a moderate-intensity exercise program, as long as there is no change in health status; and those who develop signs or symptoms of cardiovascular, metabolic, or renal disease should discontinue exercise and seek medical clearance before resuming exercise of any intensity. For physically inactive asymptomatic individuals, they may begin a light- to moderate-intensity exercise program without medical clearance and gradually progress following the ACSM ExRx guidelines. Physically inactive individuals with known cardiovascular, metabolic, or renal disease, and/or those with signs or symptoms suggestive of these diseases, should seek medical clearance before initiating an exercise program of any intensity. Evidence that has emerged since 2015 has substantiated that these ACSM recommendations have reduced barriers to exercise participation compared to earlier versions (3). Now 10 years later, we are proposing another paradigm shift to the ACSM exercise preparticipation health screening recommendations. Our call to action is based upon the following principles and developments that have occurred since 2015: Encourage exercise for all, even those considered to be high risk. The evidence is clear that the largest cardiovascular health benefits occur when sedentary behavior is avoided at the individual and population level (4–6). The safest way to avoid sedentary behavior is to start with light-intensity PA and gradually progress as tolerated following the ACSM ExRx guidelines (2,7). Any short-term exercise-related absolute risk is miniscule (i.e., one event in 1.5 million hours of exercise only with vigorous intensity exercise) and strongly outweighed by its long-term health benefits, notably in those considered to be high risk (1–4). Replace medical clearance with medical evaluation. Clearance has no meaning in the ACSM recommendations beyond having a medical professional taking the responsibility to tell a patient it is okay to exercise — when, in fact, it is impossible to create a “zero-risk” situation by medically clearing someone to exercise. Indeed, the risk of an acute cardiovascular event is almost always the result of a sudden and often unpredictable vascular change leading to a pathologic (and symptomatic) abnormality (8). The medical evaluation consists of: 1) at minimum, seeing a primary care provider (PCP) for routine preventive care visits to address cardiovascular disease (CVD) risk factor modification as well as address any abnormal examination or laboratory findings per preventive care guidelines and recommendations (6), and 2) for any new or changing signs or symptoms, seek further evaluation, either by a PCP or relevant subspecialist. Focus on signs or symptoms versus disease presence. CVD risk factors simply correlate with an increased burden of CVD, typically coronary atherosclerosis (1). Thus, treating and managing modifiable CVD risk factors is a goal of primary prevention (6). However, anyone experiencing a new onset or change in signs or symptoms, regardless of their PA level, should seek a medical evaluation. With these principles and developments in mind, we propose the following paradigm shift to reduce the need for a medical evaluation prior to exercise considering: 1) the individual's current PA level, 2) presence of signs or symptoms and/or known CVD or DM, and 3) exercise intensity (see Figure). The conceptual shift we propose is to incorporate chronic kidney disease within CVD because, although chronic kidney disease confers increased risk, this risk is not usually modifiable outside of its association with CVD (6). DM, on the other hand, is known as a coronary artery disease equivalent and should be treated as such (6). Due to the unpredictable nature of a cardiovascular event (8), we also have eliminated the use of the term asymptomatic and refer to only signs or symptoms suggestive of CVD and DM.Figure: The Proposed Conceptual Shift in the Exercise Preparticipation Health Screening Guidelines to Reduce the Need for Medical Evaluation. ACSM = American College of Sports Medicine; CVD = cardiovascular disease (Peripheral arterial disease, cerebrovascular disease or stroke, coronary heart disease, acute coronary syndrome, mycardial ischemia, or myocardial infarction); DM = diabetes mellitus; ExRx = exercise prescription. Exercise Participation = Participates in regular exercise ≥30 Minutes at Moderate-intensity physical activity on ≥3 days per week for ≥3 Months or the 3 M Rule Medical Evaluation consists of: 1) at minimum, seeing a primary care provider routinely for preventive care visits to address CVD risk factor modification as well as addressing any abnormal examination or laboratory findings per preventive care guidelines and recommendations, and 2) for any new or changing signs or symptoms, seek further evaluation, either by a primary care provider or relevant subspecialist. Light-Intensity Exercise = A level of physical exertion that causes slight increases in heart rate and breathing, and the individual can talk and sing easily. A Borg Rating of Perceived Exercise on the 6–20 Scale of 9–11. Metabolic energy equivalents (METs) of <3 METs. Moderate-Intensity Exercise = A level of physical exertion that causes noticeable increases in heart rate and breathing, and the individual can still talk but not sing. A Borg Rating of Perceived Exercise on the 6–20 Scale of 12–13; ≥3- < 6 METs. Vigorous Intensity Exercise = A level of physical exertion that causes substantial increases in heart rate and breathing, and the individual can only say a few words before having to take a breath and cannot sing. A Borg Rating of Perceived Exercise on the 6–20 Scale of 14–17; ≥6 METs. Signs and symptoms = dizziness, difficulty breathing while lying down, forceful or fast heart rate, ankle or limb pain or swelling, chest related pain discomfort, claudication or pain in the legs, shortness of breath, or murmur or heart sound. Signs and symptoms may occur at rest or while exercising. The patient should be educated about signs and symptoms because they often precede an acute cardiac event. Adapted from (1,2) and Pescatello L.S., Wu Y., Panza G.A., et al. Development of a novel clinical decision support system for exercise prescription among patients with multiple cardiovascular disease risk factors. Mayo Clin Proc Innov Qual Outcome 2021;22 (1):193–203.For individuals who are physically active (see Figure), defined as participating in regular PA of ≥30 Minutes of Moderate-intensity PA on ≥3 d/wk for ≥3 Months (i.e., the 3M rule) (1,2): with no signs or symptoms or without known CVD or DM, continue their usual exercise program and gradually progress as tolerated following the ACSM ExRx guidelines (2); with no signs or symptoms but with known CVD or DM, continue with their usual moderate-intensity exercise program, and if they have had a medical evaluation within the last 12 months, they may progress to vigorous intensity exercise, as long as there is no change in health status; and who develop signs or symptoms, regardless of disease status, discontinue exercise and seek medical evaluation before resuming exercise of any intensity. For individuals who are physically inactive (see Figure): with no signs or symptoms or CVD and DM, they may begin a light- to moderate-intensity exercise program without medical evaluation and gradually progress following the ACSM ExRx guidelines (1,2); with known CVD or DM, a medical evaluation is not needed to begin light-intensity exercise (7), while a routine medical evaluation is recommended in the last 12 months to begin moderate-intensity exercise, as long as there is no change in health status; and who develop signs or symptoms, regardless of disease status, should discontinue exercise and seek medical evaluation before resuming exercise of any intensity. Our call for action to reduce the need for a medical evaluation to exercise encourages exercise for all, including those considered to be high risk, and focuses on signs or symptoms versus disease presence. The paradigm shift we propose departs from the ACSM recommendations in the following ways (Figure): regular PA is defined by the 3M rule; medical clearance is replaced by medical evaluation, including during routine clinic appointments; chronic kidney disease is incorporated into CVD; the presence of signs or symptoms replaces the term asymptomatic; and for individuals who have CVD or DM but no signs or symptoms, if they are physically inactive, begin light-intensity exercise versus seeking medical evaluation before beginning exercise of any intensity, and a routine medical evaluation is recommended in the last 12 months to begin moderate-intensity exercise, as long as there is no change in health status. Our call to action even more strongly reinforces the original intent of the ACSM recommendations to reduce unnecessary barriers to adopting and maintaining a regular exercise program and/or a physically active lifestyle and promote the public health message that regular PA should be encouraged for all, even those considered to be high risk.