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Am Fam Physician. 1999;59(3):693-697

The American College of Sports Medicine (ACSM) and the American Heart Association (AHA) have developed recommendations for cardiovascular screening of participants in physical activities at health/fitness facilities. The recommendations also discuss the qualifications for staff working at such facilities and the policies that should be in place to ensure that staff respond expeditiously and appropriately to medical emergencies.

The recommendations were subjected to peer review by representatives from the ACSM, the AHA, the American College of Cardiology, the International Health Racquet and Sports Clubs Association and the Young Men's Christian Association They are published in Circulation (vol. 97, pp. 2283–93). A single reprint of the document, titled “Recommendations for Cardiovascular Screening, Staffing, and Emergency Policies at Health/Fitness Facilities,” may be obtained by calling 800-242-8721 or by writing the American Heart Association, Public Information, 7272 Greenville Ave., Dallas, TX 75231-4596. The document is reprint No. 71-0140.

In addition to cardiovascular screening of prospective clients, the recommendations include information on risk stratification, the qualifications of personnel in health/fitness facilities, the emergency policies needed in fitness facilities and general considerations for selecting a health/fitness facility. The following highlights the ACSM and AHA recommendations.

Screening Prospective Members

The recommendations note that cardiovascular screening at health/fitness facilities is increasingly important because of the trend in cardiac rehabilitation to refer low-risk, stable patients to community facilities instead of specialized, costly cardiac programs. For this reason, the number of clients with a history of cardiovascular disease will likely increase at health/fitness facilities.

According to the recommendations, all facilities that offer exercise equipment or services should perform cardiovascular screening of new members. Preparticipation screening should identify both persons who are known to be at risk of a cardiac event during exercise and persons without risk factors. The recommendations advocate the use of a self-administered questionnaire, completed by prospective clients, to elicit information about cardiovascular fitness (see the accompanying questionnaire).

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The recommendations state that efforts should be made to educate all prospective members about the importance of obtaining a health appraisal and, if indicated, a medical evaluation before beginning exercise training. Persons with known cardiovascular disease who fail to complete the questionnaire or who fail to obtain a recommended medical evaluation may be prohibited from participating in activities at the fitness facility to the extent permitted by the law. Persons without known cardiovascular disease who do not obtain a medical evaluation as recommended may be permitted to participate if they sign a release or waiver.

Classifying Cardiovascular Risk

The recommendations categorize clients at health/fitness facilities into four classes of risk, depending on the initial health appraisal and, if indicated, the medical evaluation. The categories are as follows:

Class A: Persons who are apparently healthy. This group includes younger persons who are healthy and other persons, regardless of age, who are either healthy or at increased risk but have a normal maximal exercise test.

Class B: Persons with known, stable cardiovascular disease with a low risk of problems during vigorous exercise but a slightly greater risk than apparently healthy persons. This category includes persons with coronary artery disease, valvular heart disease, congenital heart disease, cardiomyopathy and abnormalities on exercise testing. Persons with abnormal findings on exercise testing may include those whose heart disease places them in New York Heart Association (NYHA) Class I or II.

Class C: Persons at moderate or high risk for cardiac complications during exercise and/or who are unable to self-regulate activity or understand the recommended activity level. Persons in this category may have previously had two or more myocardial infarctions, may be in NYHA Class III or greater and may have ischemic ST-segment depression of 1 mm or exercise-induced angina at a workload of 6 METS (metabolic equivalents) or less. Exercise for persons in Class C should be prescribed by medical personnel. In addition, medical supervision, monitoring for adverse signs and symptoms, electrocardiographic monitoring of heart rate and rhythm, and blood pressure monitoring are recommended during initial exercise sessions until the safety of exercise for such individuals is documented.

Class D: Persons who have unstable conditions and activity restriction. This group includes persons with unstable angina, uncompensated heart failure, uncontrolled arrhythmias, severe and symptomatic aortic stenosis, hypertrophic cardiomyopathy or cardiomyopathy from recent myocarditis, severe pulmonary hypertension and other conditions that could be aggravated by exercise. No physical activity is recommended for conditioning purposes in such persons.

Staffing and Emergency Policies

The report decribes five levels of health/fitness facilities. Level 1 facilities have only an unsupervised exercise room and no personnel. Level 2 facilities have a single exercise leader to supervise the exercise room. Level 3 facilities are commonly called fitness centers, and are intended for healthy clients. Staff at level 3 facilities may include a general manager, a health/fitness instructor and an exercise leader. Level 4 facilities serve clinical populations, and level 5 facilities provide medically supervised exercise programs.

The recommendations state that personnel at health/fitness facilities must meet the professional standards as stipulated by ACSM. Staff at levels 3, 4 and 5 facilities may include the general manager of the facility, the medical liaison, the fitness instructor and the exercise leader. The medical liaison may be a physician, a registered nurse trained in advanced cardiac life support or an emergency medical technician. Medical liaisons are recommended for facilities that are levels 2, 3, 4 and 5.

According to the recommendations, all health/fitness facilities must have emergency policies and procedures, and such procedures must be reviewed and practiced regularly. In addition, staff who supervise exercise activities should be skilled in basic life support. Emergency drills are recommended once every three months, or more often if staff turnover mandates it. The recommendations state that staff training and preparedness for emergencies are especially important at facilities that serve persons with medical conditions such as cardiovascular disease.

An emergency plan is recommended for all types of health/fitness facilities, and emergency equipment ranges from a telephone and “what-to-do-in-case-of-an-emergency” signs in exercise rooms at level 1 facilities to resuscitation equipment at level 5 facilities. Levels 2, 3 and 4 facilities should have a telephone, in-case-of-emergency signs, a blood pressure kit and a stethoscope available. In addition to this equipment, level 5 facilities (supervised cardiac rehabilitation) should also have a defibrillator, oxygen and a crash cart.

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