ACSM-EP Health Appraisal & Risk Assessment — Questions and Answers
Question 1: A 45-year-old inactive man has no signs or symptoms and no known cardiovascular, metabolic, or renal disease. He wants to begin a moderate-intensity walking program. According to the ACSM preparticipation screening algorithm, what is the appropriate recommendation?
- Complete a maximal graded exercise test with ECG before starting
- Obtain written physician clearance before any exercise
- Begin light-to-moderate intensity exercise and progress gradually without medical clearance (Correct answer)
- Wait until a fasting lipid panel and resting ECG are completed
Correct answer: Begin light-to-moderate intensity exercise and progress gradually without medical clearance
An asymptomatic person without known CVMR disease who plans moderate-intensity exercise does not need medical clearance under the ACSM algorithm.
The current ACSM preparticipation screening algorithm considers three factors: current physical activity, known cardiovascular, metabolic, or renal (CMR) disease, and signs or symptoms. An inactive person with no disease and no symptoms may start light-to-moderate exercise and progress gradually, with no medical clearance required. Routine exercise testing or physician clearance is not needed for this person and would create an unnecessary barrier to activity. Medical clearance becomes relevant if the person has known CMR disease or symptoms, or later wants to progress to vigorous intensity.
Question 2: A 52-year-old woman exercises moderately 4 days per week for the past 6 months. She has type 2 diabetes, no symptoms, and wants to start vigorous interval training. What does the ACSM screening algorithm recommend?
- Medical clearance is recommended before progressing to vigorous intensity; she may continue moderate exercise meanwhile (Correct answer)
- She may begin vigorous intervals immediately with no further steps
- She must stop all exercise until a physician clears her
- She needs a symptom-limited graded exercise test with ECG before any exercise at all
Correct answer: Medical clearance is recommended before progressing to vigorous intensity; she may continue moderate exercise meanwhile
For a regularly active person with known CMR disease and no symptoms, medical clearance is recommended before vigorous exercise, but moderate exercise may continue.
In the ACSM algorithm, regularly active means at least 30 min of moderate-intensity exercise on 3 or more days per week for at least 3 months. If such a person has known CMR disease (diabetes counts) and is asymptomatic, she may continue moderate-intensity exercise, but medical clearance is recommended before progressing to vigorous intensity. Stopping all exercise is unnecessary, and a mandatory GXT for everyone is not part of the algorithm. If symptoms appeared, she would stop exercise and seek medical evaluation.
Question 3: A regularly active 38-year-old man with no known disease reports new chest pressure that appears when he runs uphill and resolves with rest. What is the most appropriate action?
- Continue training but reduce intensity by half
- Take a few weeks off and resume the same program
- Increase warm-up duration and keep training
- Stop exercising and obtain medical evaluation before resuming (Correct answer)
Correct answer: Stop exercising and obtain medical evaluation before resuming
New exertional chest discomfort is a symptom suggestive of cardiovascular disease, so exercise should stop until a medical evaluation is completed.
Signs and symptoms suggestive of CMR disease (chest discomfort with exertion, unreasonable dyspnea, dizziness or syncope, orthopnea, ankle edema, palpitations, claudication) require medical evaluation in the ACSM algorithm, regardless of activity level. Reducing intensity or lengthening the warm-up ignores a possible ischemic cause. Waiting a few weeks without evaluation delays diagnosis. Exercise resumes only after the evaluation and the healthcare provider's guidance.
Question 4: A client weighs 82 kg and is 1.78 m tall. What is his BMI and ACSM/WHO classification?
- 22.2 kg/m2, normal weight
- 25.9 kg/m2, overweight (Correct answer)
- 29.1 kg/m2, overweight
- 25.9 kg/m2, obesity class I
Correct answer: 25.9 kg/m2, overweight
BMI = 82 / 1.78^2 = 82 / 3.168 = 25.9 kg/m2, which is in the overweight range (25.0 to 29.9).
BMI = mass (kg) / height (m)^2 = 82 / (1.78 x 1.78) = 82 / 3.168 = 25.9 kg/m2. Normal is 18.5 to 24.9, overweight 25.0 to 29.9, and obesity class I starts at 30.0. A value of 22.2 would result from using a much heavier height, and 29.1 results from an arithmetic error. BMI does not distinguish fat from lean mass, so waist circumference and body composition add information.
Question 5: A client's resting blood pressure, measured correctly on two occasions, is 134/82 mm Hg. Using the ACC/AHA classification adopted by ACSM, which category applies?
- Normal
- Elevated blood pressure
- Stage 1 hypertension (Correct answer)
- Stage 2 hypertension
Correct answer: Stage 1 hypertension
Systolic 130 to 139 or diastolic 80 to 89 mm Hg is stage 1 hypertension.
Under ACC/AHA 2017 criteria, normal is below 120/80, elevated is systolic 120 to 129 with diastolic below 80, stage 1 is systolic 130 to 139 or diastolic 80 to 89, and stage 2 is 140/90 or higher. Both readings, 134 and 82, fall in stage 1, so the higher category governs. Hypertension is a positive risk factor and is a key part of health appraisal. A client with uncontrolled values far above 200/110 would need clearance before exercise testing.
Question 6: A client's fasting plasma glucose is 112 mg/dL on two occasions. How is this value classified?
- Prediabetes (impaired fasting glucose) (Correct answer)
- Normal fasting glucose
- Diabetes mellitus
- Hypoglycemia
Correct answer: Prediabetes (impaired fasting glucose)
A fasting glucose of 100 to 125 mg/dL indicates prediabetes (impaired fasting glucose).
Normal fasting glucose is below 100 mg/dL, prediabetes (impaired fasting glucose) is 100 to 125 mg/dL, and diabetes is 126 mg/dL or higher on repeat testing. Hypoglycemia is typically below 70 mg/dL. Impaired fasting glucose is a cardiometabolic risk factor in the ACSM health appraisal, and regular exercise with weight loss lowers progression to type 2 diabetes.
Question 7: Which condition is an absolute contraindication to exercise testing?
- Resting blood pressure of 138/86 mm Hg
- Well-controlled type 2 diabetes
- Acute pulmonary embolism (Correct answer)
- Stable mild persistent asthma
Correct answer: Acute pulmonary embolism
Acute pulmonary embolism is an absolute contraindication to exercise testing.
Absolute contraindications include acute myocardial infarction within 2 days, ongoing unstable angina, uncontrolled symptomatic arrhythmia, symptomatic severe aortic stenosis, decompensated heart failure, acute pulmonary embolism or infarction, acute myocarditis or pericarditis, and acute aortic dissection. Mildly elevated resting BP, controlled diabetes, and stable asthma are managed with precautions but do not prohibit testing. Relative contraindications may be overridden when benefits outweigh risks.
Question 8: During a graded exercise test, a client's systolic blood pressure falls 15 mm Hg below the previous stage despite increased workload. What should the exercise professional do?
- Increase workload to see whether pressure recovers
- Terminate the test (Correct answer)
- Continue to the next stage and recheck
- Only stop if heart rate exceeds 85% of predicted maximum
Correct answer: Terminate the test
A drop in systolic BP of more than 10 mm Hg despite increasing workload is an indication to terminate the test.
ACSM lists a decrease in systolic BP of more than 10 mm Hg with increasing workload as an indication to terminate a test (absolute when accompanied by other signs of ischemia, relative otherwise). It can signal left ventricular dysfunction or severe ischemia. Normally, systolic BP rises about 10 mm Hg per MET. Continuing or increasing workload risks serious adverse events, and reaching a target heart rate is irrelevant when this finding appears.
Question 9: Using the Tanaka equation (HRmax = 208 - 0.7 x age), what is the predicted maximal heart rate of a 50-year-old client?
- 170 beats/min
- 173 beats/min (Correct answer)
- 177 beats/min
- 180 beats/min
Correct answer: 173 beats/min
HRmax = 208 - (0.7 x 50) = 208 - 35 = 173 beats/min.
Tanaka: 208 - 0.7 x 50 = 208 - 35 = 173 beats/min. The traditional 220 - age gives 170 beats/min, which underestimates HRmax in older adults and is the likely distractor. All age-predicted equations have a standard deviation of about 10 to 12 beats/min, so they are estimates only. When possible, a measured maximum from a maximal test is preferred for setting heart rate targets.
ACSM-EP Health Appraisal & Risk Assessment
A 45-year-old inactive man has no signs or symptoms and no known cardiovascular, metabolic, or renal disease.
He wants to begin a moderate-intensity walking program.
According to the ACSM preparticipation screening algorithm, what is the appropriate recommendation?
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