American College of Sports Medicine Expert Consensus Statement to Update Recommendations for Screening, Staffing, and Emergency Policies to Prevent Cardiovascular Events at Health Fitness Facilities

Abstract

Introduction American College of Sports Medicine (ACSM) Expert Consensus Statements are documents created by consensus among a small group of recognized leaders in the field. These statements are designed to present existing knowledge, highlight knowledge gaps, and present recommendations for clinical practice. This present expert consensus statement updates and replaces the prior ACSM statement entitled “AHA/ACSM Joint Position Statement: Recommendations for Cardiovascular Screening, Staffing, and Emergency Policies at Health/Fitness Facilities,” which was published in June 1998 (1). Many aspects of this prior statement remain valid, specifically the emphasis on the health benefits of exercise and physical activity (PA), the value of a well-trained fitness facility staff, and the necessity of developing and practicing an emergency response plan. On the other hand, the prior statement emphasized providing “recommendations for cardiovascular screening of all persons (children, adolescents, and adults) before enrollment or participation in activities at health/fitness facilities.” The present consensus statement, in contrast, seeks to minimize screening and other factors that may impede the use or the availability of physical fitness facilities. This newer approach is based on four established concepts: 1) The increasingly recognized health benefits of even low levels of PA (2). 2) The rarity of cardiovascular events provoked by PA among apparently healthy adults (3), even among those with established cardiovascular disease (CVD) (4). 3) The recognition that preexercise screening strategies are a barrier to PA because they often require additional medical testing for clearance (5). 4) The recognition that immediate assistance provided by nonmedical personnel, such as dialing 911, initiating bystander cardiopulmonary resuscitation (CPR), and using an automated external defibrillator (AED) can greatly reduce the morbidity and mortality of acute cardiac events. This updated document seeks to provide suggestions and guidance on establishing emergency policies and plans for a variety of exercise settings including professionally staffed fitness facilities, unstaffed facilities, such as community recreation and hotel fitness facilities, and sporting event venues, such as school athletic facilities. It is beyond the scope of this document to address specifically all types of exercise facilities so this statement emphasizes general safety recommendations based, in part, on the comprehensive recommendations for emergency planning and policies available from prior ACSM publications (6). The Importance of PA and Cardiorespiratory Fitness in Health and Longevity Regular PA provides significant health and longevity benefits for all participant groups as detailed by the second edition of the U.S. Department of Health and Human Services PA Guidelines for Americans released in 2018 (7). These updated guidelines are based on the PA Guidelines Advisory Committee's Scientific Report (PAGAC), which reviewed and summarized the current body of scientific evidence supporting the value of PA for human health and function (8). The list of health benefits attributable to PA has expanded significantly since the original 2008 PA Guidelines. The 2018 PAGAC Scientific Report identified a direct relationship between sedentary behavior and all-cause mortality, incidence and mortality of CVD, incidence of type 2 diabetes, as well as incidence of endometrial, colon, and lung cancer (9–11). The report also demonstrated that mortality risk increases progressively with increased sitting time. This risk is attenuated with increased volumes of moderate to vigorous PA (MVPA), with the highest levels of MVPA affording the greatest risk reduction (12). In addition to these findings, the PAGAC Scientific Report (7,8) also provided strong evidence for the following: –Greater volumes of MVPA are associated with reduced risk of excessive weight gain and obesity in adults and children. –More physically active pregnant women are less likely to gain excessive weight in pregnancy and are less likely to develop gestational diabetes or postpartum depression than their less active peers. –Greater volumes of PA are associated with a reduced risk of dementia and improve other aspects of cognitive function (7,8). –PA reduces the risk of falls and fall-related injuries in older adults. The 2008 report noted that MVPA reduced breast and colon cancer risk. The 2018 report expanded the type of cancers whose risk was reduced with MVPA to include endometrial, esophageal, kidney, lung, stomach, and bladder cancers. The 2018 report also concluded that for individuals with the most common, noncommunicable chronic conditions such as osteoarthritis, hypertension, and type 2 diabetes, regular PA could reduce the risk of developing a new chronic condition, reduce the risk of progression of an existing chronic condition, and improve quality of life and physical function. Exercise and regular PA have long been known to decrease established CVD risk factors (5,13). Exercise has positive effects on lipoprotein profiles, blood pressure, C-reactive protein, insulin sensitivity, and may play an important role in weight management. Healthy middle-aged and older adults with greater cardiorespiratory fitness at baseline, and those who improve their cardiorespiratory fitness over time, have a lower all-cause and CVD morbidity and mortality. There also is a decreased risk of clinical events associated with greater cardiorespiratory fitness in those with preexisting CVD (5,7,13). Epidemiological studies have shown that 150 min·wk−1 of moderate PA or 75 min of vigorous PA are associated with decreased rates of CVD and premature mortality (5,13). Significant reductions in CVD and premature mortality occur at PA volumes well below these targets, starting at even half of the recommended volume (14). Data support the target PA goal of 150 to 300 min·wk−1 of MVPA, but the 2018 guidelines highlight that there are health benefits associated with any level of PA (7). For those individuals who perform little to no MVPA, even replacing sedentary behavior with light-intensity PA reduces the risk of all-cause mortality, CVD incidence and mortality, and the incidence of type 2 diabetes (7). A pooled analysis of six prospective cohort studies on the association between leisure time activity and mortality risk demonstrated that there is neither an upper nor lower threshold for these benefits to occur (15). The greatest benefits are seen with the initiation of MVPA, and there is no increased mortality risk at activity volumes up to four times the current guideline amounts. Also, at least 70% of the maximal benefit is achieved by meeting current MVPA guidelines of 150 min·wk−1 (15). The 2008 Guidelines concluded that health benefits only accrued with at least 10 min of continuous MVPA, but the 2018 Committee concluded that every minute of MVPA counts toward the goal (16–18). These findings provide the public with various options on how to achieve their PA goals. The Cardiovascular Risks of PA Although habitual PA reduces the risk of CVD, vigorous PA (defined as ≥60% of functional capacity or ≥6 metabolic equivalents [METs; 1 MET = 3.5 mL O2·kg−1·min−1]) acutely increases the risk of sudden cardiac death (SCD), acute myocardial infarction (AMI), and hemorrhagic (19) and ischemic stroke (20). Possible triggering mechanisms for plaque rupture and acute coronary thrombosis (Table 1) (21) or threatening ventricular arrhythmias have been suggested (Fig. 1) (23).Table 1: Potential triggering mechanisms of AMI by strenuous physical exertion. aFigure 1: Physiological alterations accompanying acute exercise and recovery and their possible sequelae. HR, heart rate; SBP, systolic blood pressure; MV˙O2, myocardial oxygen consumption; CHD, coronary heart disease. Adapted from (23).An increase in platelet aggregation, which may initiate or contribute to coronary thrombosis, has been reported in habitually sedentary individuals who engaged in unaccustomed high-intensity PA, but not in physically trained individuals (24). The pathology of exertion-related acute cardiovascular events varies with the victim's age. Structural cardiovascular abnormalities, most notably, hypertrophic cardiomyopathy (HCM) and high-risk congenital anomalous coronary anatomy, are commonly cited causes of SCD in younger persons, although recent autopsy studies of exercise-related SCD in high school and college athletes have identified no structural cause at autopsy, a condition called either sudden arrhythmic death syndrome (25) or SCD with a structurally normal heart (26). A study of athletic participants aged 12 to 45 years reported 74 cases of sudden cardiac arrest (SCA) during 18.5 million person-years of observation, yielding an incidence of 0.76 cases per 100,000 athletes per year (27). Of these cases, 16 occurred during competitive sports, of which 44% survived, whereas the remaining 58 occurred during noncompetitive sports, of which 44% also survived. In contrast to previous studies which identified HCM as the primary cause of SCD in young athletes (28), genetic structural abnormalities, such as HCM and arrhythmogenic right ventricular cardiomyopathy, caused only 8% and 5% of the SCAs, respectively (27). Atherosclerotic CVD is the most common autopsy finding in individuals older than 40 years who experience SCA and SCD during or immediately after strenuous exercise (29). Nevertheless, the routine referral of asymptomatic middle-aged and older individuals for medical clearance before starting an exercise program appears unwarranted and presents needless barriers to exercise adoption (30,31). On the other hand, physically inactive individuals with known cardiovascular, metabolic or renal disease, or signs/symptoms that are suggestive of these diseases should seek medical attention before starting an exercise program, regardless of the intensity (5). A study of nontraumatic sports deaths in 126 high school athletes (115 men and 11 women) and 34 college athletes (31 men and 3 women) over 10 years found that estimated death rates were five-fold higher in male athletes than in female athletes (32). The incidence of exertion-related SCD and AMI also is lower in women than men. The risk of SCD during or immediately after exercise is 15-fold to 20-fold higher in men, a rate much higher than the two-fold to three-fold higher male SCD rate reported in epidemiologic studies not limited to exercise (33). The rate of SCA during full and half marathon running also is higher among men than women (0.90 vs 0.16 per 100,000) (34). The absolute incidence of exercise associated AMI also is slightly higher in men versus women, 0.046 versus 0.015 person hours (35); however, most studies have not found a sex difference in the relative risk (RR) of myocardial infarction during physical exertion (33). The incidence of cardiovascular events during very light- to moderate-intensity PA is extremely low and similar to that reported under resting conditions. However, vigorous PA, especially when sudden, sporadic, or involving high levels of anaerobic metabolism, does transiently increase the risk for AMI and SCD in susceptible individuals (36). Additional modulators of exercise risk may include superimposed environmental stress, including heat/humidity (37), cold (38), water immersion (39), altitude (40,41), as well as the excitement of competition (42). These accentuate the cardiac and respiratory responses to exercise, and thereby increase the risk of exertion-related acute cardiac events. The rate of exercise-related AMI and SCD is extremely low whether estimated as events per participant or per hour of exercise. The death rate for joggers is approximately one jogging death per year for every 7620 middle-aged joggers in Rhode Island, corresponding to approximately one death per 396,000 h of jogging (43), although this rate was 7.6 times the hourly death rate during less strenuous activities. Vigorous recreational PA is associated with one nonfatal and one fatal event per 1,124,200 and 886,526 h of participation, respectively (44). The incidence of exercise-related cardiovascular events at YMCA sports centers has been estimated at one death per 2,897,057 person-hours, although exercise intensity was not reported (45). The rate of exercise-related nonfatal and fatal cardiovascular events in apparently healthy adults from fitness facilities also is low at one per 1,124,200 and one per 887,526 person hours, respectively (46). Two studies (47,48) and a related review (49) suggest that vigorous PA transiently increases the combined RR of AMI and SCD approximately two-fold to 107-fold compared with nonvigorous exercise or rest, and that the RR decreases with increasing frequency of regular vigorous exercise (Fig. 2) (30,47).Figure 2: RR of AMI at rest and during vigorous physical exertion (≥6 metabolic equivalents) in sedentary and physically active individuals, with specific reference to the habitual frequency of vigorous exertion (days/week). Adapted from (30,47) with permission.Nevertheless and despite the increased RR, the absolute risk of these events remains low and between 1 per 565,000 (50) and 1 per 2,600,000 h of exercise (49). The Physicians' Health Study and Health Study reported only one SCD per million hours of vigorous PA in men and per million hours of MVPA in In these studies highlight the rarity of cardiovascular during exercise and suggest that exercise is for most have a of the at increased risk for exercise-related acute cardiovascular events (Table 2) 2: associated with exercise-related cardiac events. acute cardiovascular events are often by or which should immediate of exercise and medical review of There is evidence that high-intensity provides or even greater increases in exercise capacity compared with moderate-intensity continuous exercise in persons with and chronic disease. to the of high-intensity exercise 2 to min with of moderate or recovery exercise during the exercise There are of which can in the and intensity of the high-intensity and recovery However, there is the safety of in adults with known or coronary disease A of cardiovascular event rates during versus in cardiac involving hours, event rates of 1 per and 1 per a higher risk for with but there were only events fatal cardiac arrest during and 2 nonfatal cardiac during These low event rates of the risk associated with a review the cardiovascular associated with in for with or heart on studies involving participants to there was only one nonfatal cardiovascular review of studies including and and reported no deaths or cardiac events among groups Although appears to provide a to additional studies the safety of are before can in individuals with known or especially in nonmedical settings epidemiologic studies have shown that individuals are approximately to times likely to during as compared with their regardless of the risk or the of as by coronary these in is important to that the absolute risk associated with of exercise is extremely the RR is related to the habitual level of PA, and that regular exercise, including activity reduces the risk of acute cardiovascular events by up to a habitually sedentary appears to than a physically active the likely benefits of cardiorespiratory fitness and chronic to exercise in cardiovascular is important that individuals exercise at a time of regardless of the hour (36). exercise-related cardiovascular are less common than sports and recreational such as and regular emergency immediate cardiopulmonary and the use of have increased rates in the general and running Cardiovascular of Health and fitness facilities the of including individuals with established and a including screening is of to safety in these has been as a of at high risk for events during exercise, thereby providing an for disease and with risk The absolute risk of AMI SCD during exercise is and is by There is a sex with approximately likely to experience an event during exercise (34). Data from the U.S. a relationship between increasing and SCA incidence by increases in the of coronary disease PA also are an important of risk. demonstrated a strong relationship between risk of sudden death and hours per of PA among men known heart disease. The of specifically diabetes and renal disease, in to their association with appears to increase the risk of events during exercise types of PA have been associated with higher of sports, such as and to the among young competitive athletes and recreational fitness facility facilities exercise should cardiovascular screening of all new and prospective The ACSM for among adults and guidelines for this have been published (5). The primary goal of is to new or of a health or fitness facility that should for medical prior to initiation of exercise. the approach to of PA by of CVD risk established and suggestive of However, CVD risk has been from the most recent ACSM to low for the of disease (Fig. 3) (5). The ACSM has been to 1) a of habitual exercise 2) the of established and renal 3) and the recognition of and of This approach is for use in health and fitness facilities as use does not require medical but does trained and should for new and prospective of these facilities at the time of enrollment an with facility or the for medical on an exercise program and young competitive to as recommended by the American College of may studies have shown that can and does for the reduction of events during exercise has to Exercise health screening for exercise participation, PA at least min at moderate intensity on at least 3 for at least the 3 exercise, to or 2 to an intensity that causes increases in and exercise, to or 3 to an intensity that causes increases in and exercise ≥60% or ≥6 an intensity that causes increases in and or disease. disease, type 1 and 2 diabetes and at rest or during in the or other that may from of at rest or with or or or known heart or or of with activities. from a health to in exercise. Guidelines for Exercise and with from Recommendations for A emergency response is to providing a for exercise including of facility safety and also are of a comprehensive risk plan. 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The present document emphasizes the of the of facility emergency and the of emergency The of this document are to reduce the cardiovascular of exercise barriers to participation in an active

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