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Getting to the Heart of Pre-Exercise Screening

A preparticipation health screening helps trainers and prospective clients safely launch into an exercise program. When the American College of Sports Medicine updated its pre-exercise screening guidelines 3 years ago, it made one major shift: It stopped recommending the use of a tool to assess cardiovascular disease risk.

This may seem like an odd choice, given that exercise is so central to reducing CVD risk. Why wouldn’t trainers want to use a tool to help people understand their likelihood of developing heart disease? It turns out that ACSM’s rationale for the change underscores a critical insight regarding exercise participation and adherence.

The Roots of ACSM’s Shift

In 2015, ACSM introduced new prescreening guidelines developed by a roundtable of ACSM pros with practitioner, clinical, educational and scientific experience in physical activity and exercise (Riebe et al. 2015). These professionals introduced a new model of pre-exercise health-screening recommendations based on the exerciser’s desired intensity; how much physical activity the person currently does; and any symptoms of known metabolic, cardiovascular or kidney diseases.

The professional panel affirmed that it’s important to identify CVD risk factors to help clients prevent or manage heart disease. But the panel made a point of redefining the recommendations for telling people about their risk of developing heart disease. ACSM did this because it wanted to remove some barriers that might prevent people from using exercise to stay healthy.

Why ACSM Updated Its Health-Screening Guidelines

Riebe and colleagues (the panel) explain that CVD risk-factor profiling can have a downside: unnecessary referrals to a healthcare provider for clearance to start an exercise program. Unfortunately, these doctors’ visits may result in false-positive test results, which can trigger personal stress in clients and lead to more treatments that impose unnecessary financial and personal burdens. These disadvantages can discourage the adoption of a physically active lifestyle.

Riebe et al. note that motivating people to adopt a lifestyle of regular physical activity is a considerable challenge; therefore, pre-exercise health-screening guidelines should not unnecessarily deter people from becoming more active.

Why wouldn’t trainers want to use a tool to help people understand their likelihood of developing heart disease? It turns out that ACSM’s rationale for the change underscores a critical insight regarding exercise participation and adherence.

How Safe Is Exercise?

In their review, Riebe et al. concede that sudden vigorous physical exertion can elevate the acute risk of two potentially fatal heart problems:

  • sudden cardiac death (SCD), when the heart’s electrical system malfunctions and the heart beats dangerously fast
  • acute myocardial infarction (AMI), better known as a heart attack, when one or more coronary arteries have a blockage

However, the researchers note that SCD occurs once in every 1.5 million episodes of vigorous physical exertion in men and once in 36.5 million hours of moderate-to-vigorous exertion in women. All of the published data on SCD and AMI during exercise says these events are very rare, suggesting that exercise is safe for most people, the researchers say. They add that physically inactive people face a greater total risk for an abrupt cardiac event (any incident that damages heart muscle) than their physically active counterparts.

Even though increasing age is a CVD risk factor, there is no evidence that age is a strong predictor of SCD or AMI (Riebe et al. 2015). The researchers add that there’s little data on cardiovascular risk during resistance training, but that risk appears to be low. Most importantly, regular physical activity shows an inverse relationship with SCD and AMI, meaning the more people exercise consistently, the less likely they are to have a life-threatening heart complication.

Should Fitness Pros Still Assess for CVD Risk?

Riebe et al. state that CVD risk assessments should not be part of the process of providing medical clearance for exercise because these assessments cannot accurately predict the likelihood of a heart attack or other CVD issues. However, the panelists still encourage exercise pros to assess clients’ CVD risk factors (see Table 1) to help prevent or manage cardiovascular and metabolic diseases.

In another guideline change, people with pulmonary disease are no longer automatically referred for medical clearance. Pulmonary disease does not increase the risk of fatal cardiovascular events during or immediately after exercise.

New ACSM Pre-Exercise Health-Screening Algorithm

An algorithm is a set of steps that can be followed to solve a problem. The new pre-exercise health-screening algorithm (Riebe et al. 2015) shows the steps to follow for exercisers (Table 2) and nonexercisers (Table 3). Exercisers are described as persons who have engaged in planned, structured activity of moderate intensity for at least 30 minutes on at least 3 days per week for at least the past 3 months (Riebe et al. 2015). Light-intensity exercise is defined as exercise that causes a slight increase in heart rate and breathing (30% < 40% of heart rate reserve, 9–11 rating of perceived exertion). By comparison, moderate-intensity exercise causes a noticeable increase in heart rate and breathing (40% < 60% of heart rate reserve, 12–13 RPE), and vigorous exercise causes a substantial increase in heart rate and breathing (≥60% heart rate reserve, ≥14 RPE).

Find Out More

To reduce the risk of exercise-related cardiovascular health complications, fitness pros should always ensure that clients follow an individualized, safe and effective exercise design that progressively transitions frequency, intensity, time, exercise type, volume and progression (known as the FITT-VP principle of exercise program design). To learn more, see ACSM’s Guidelines for Exercise Testing and Prescription (10th ed.), which has the most up-to-date information on exercise guidelines for fitness pros who do exercise tests and design exercise programs (ACSM 2018).

Len Kravitz, PhD, CSCS, is the program coordinator of exercise science at the University of New Mexico, where he has received the Outstanding Teacher of the Year and Presidential Award of Distinction. In 2016, in addition to being inducted into the National Fitness Hall of Fame, he received the canfitpro Specialty Presenter Award.

© 2018 by IDEA Health & Fitness Inc. All rights reserved. Reproduction without permission is strictly prohibited.


ACSM (American College of Sports Medicine). 2018. ACSM’s Guidelines for Exercise Testing and Prescription (10th ed.) Philadelphia: Wolters Kluwer.

AHA (American Heart Association). 2018. Understand your risks to prevent a heart attack. Accessed July 26, 2018: heart.org/HEARTORG/Conditions/HeartAttack/UnderstandYourRiskstoPreventaHeartAt

NHLBI (National Heart, Lung, and Blood Institute). 2017. Lower heart disease risk. Accessed July 24, 2018: nhlbi.nih.gov/health/educational/hearttruth/lower-risk/risk-factors.htm.

Riebe, D., et al. 2015. Updating ACSM’s recommendations for exercise preparticipation health screening. Medicine & Science in Sports & Exercise, 47 (11), 2473–79.

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