AHA Preparticipation Test Sends Most Would-Be Exercisers for Doc Consult

January 20, 2014

ROYAL OAK, MI — If every adult over age 40 followed the screening advice of the American Heart Association (AHA) and American College of Sports Medicine (ACSM), more than 93% of men and 95% of women would need to consult a physician before starting an exercise program[1].

According to Dr Geoffrey Whitfield (Centers for Disease Control and Prevention, Atlanta, GA) and colleagues, any preparticipation screening tool that refers more than 90% of individuals for a physician consult is unlikely to be effective at reducing the risk of cardiovascular disease. Their findings were published online January 13, 2014 in Circulation.

In fact, the researchers say that such excessive referrals "may place an unnecessary burden on healthcare infrastructure" and "actually present a barrier to exercise adoption due to the financial and time requirements involved" in seeing a physician.

In an accompanying editorial, Dr Barry Franklin (William Beaumont Hospital, Royal Oak, MI) states that the cardiovascular benefits of exercise outweigh the risks for a vast majority of adults, especially if they engage in light-to-moderate activity[2]. Asymptomatic men and women should be able to get active without consulting a doctor unless they have specific medical questions.

In the editorial, Franklin quotes Dr Per-Olof Astrand, a pioneer in the field of physiology and exercise testing: "A medical evaluation is more urgent for those who plan to remain inactive than for those who intend to get into good physical shape."

Applying the AAPQ to NHANES

In their assessment of pre-exercise screening measures, Whitfield and colleagues tested the AHA/ACSM Preparticipation Questionnaire (AAPQ). The AAPQ is a self-screening questionnaire that can be used in multiple settings, such as sports clubs, gyms, and private use, by individuals starting an exercise program.

Researchers used data from the National Health and Nutrition Examination Survey (NHANES) and applied the AAPQ to US adults aged 40 years and older to determine what proportion would receive recommendations for preparticipation screening. They assumed that the 3326 men and 3459 women would have responded to the AAPQ the same as they did for the NHANES questionnaire.

The group found that 95.5% of women and 93.5% of men across all ages would be referred for a physician consult prior to starting exercise based on the AAPQ. For those 70 years or older, more than 99% of men and women would be referred.

The researchers point out that although the recommendation to see a physician was typically lower in adults currently meeting recommended physical-activity goals, 82.5% of currently active women aged 40 to 44 years and 79.8% of currently active men of the same age would be referred to a physician based on the AAPQ. Medication use and older age were two common characteristics that could trigger the AAPQ to suggest a physician consult before exercising.

"The high referral proportions are likely due to the breadth of topics covered by the AAPQ, and future revisions should focus on narrower ascertainment of history and symptoms directly relevant to exercise safety," write Whitfield et al. "Unless significant revisions are made to the AAPQ, it is of dubious utility among adults aged 40 years or older."

In contrast, the Physical Activity Readiness Questionnaire performed a little better, but 68.4% of individuals would still be referred to a physician based on the test.

The authors and editorialist reported no conflicts of interest.

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