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What Will Acsm Risk Stratification Form Be Like In The Next 8 Years? | Acsm Risk Stratification Form

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Importance  Cardiovascular ache (CVD), which encompasses atheroscl altitude such as coronary affection disease, cerebrovascular disease, and borderline arterial disease, is the best accepted account of afterlife amid adults in the United States. Assay to anticipate CVD contest by modifying blow factors is currently a by CVD blow appraisal with accoutrement such as the Framingham Blow Score or the Pooled Accomplice Equations, which coat abandoned blow to acquaint assay decisions.

acsm risk stratification form - Heart.impulsar
acsm risk stratification form – Heart.impulsar | acsm risk stratification form

Objective  To amend the 2012 US Antitoxin Casework Task Force (USPSTF) advocacy on screening for coronary affection ache with electrocardiography (ECG).

Evidence Review  The USPSTF advised the affirmation on whether screening with comatose or exercise ECG improves bloom outcomes compared with the use of acceptable CVD blow appraisal abandoned in asymptomatic adults.

Findings  For asymptomatic adults at low blow of CVD contest (individuals with a 10-year CVD blow accident beneath than 10%), it is actual absurd that the admonition from comatose or exercise ECG (beyond that acquired with accepted CVD blow factors) will aftereffect in a change in the patient’s blow class as adjourned by the Framingham Blow Score or Pooled Accomplice Equations that would beforehand to a change in assay and ultimately beforehand bloom outcomes. Accessible harms are associated with screening with comatose or exercise ECG, accurately the abeyant adverse furnishings of consecutive invasive testing. For asymptomatic adults at average or aerial blow of CVD events, there is bereft affirmation to actuate the admeasurement to which admonition from comatose or exercise ECG adds to accepted CVD blow appraisal models and whether admonition from the ECG after-effects in a change in blow administration and ultimately reduces CVD events. As with low-risk adults, accessible harms are associated with screening with comatose or exercise ECG in asymptomatic adults at average or aerial blow of CVD events.

Conclusions and Recommendation  The USPSTF recommends adjoin screening with comatose or exercise ECG to anticipate CVD contest in asymptomatic adults at low blow of CVD events. (D recommendation) The USPSTF concludes that the accepted affirmation is bereft to appraise the antithesis of allowances and harms of screening with comatose or exercise ECG to anticipate CVD contest in asymptomatic adults at average or aerial blow of CVD events. (I statement)

The US Antitoxin Casework Task Force (USPSTF) makes recommendations about the capability of specific analytic antitoxin casework for patients afterwards accessible accompanying signs or symptoms.

It bases its recommendations on the affirmation of both the allowances and harms of the account and an appraisal of the balance. The USPSTF does not accede the costs of accouterment a account in this assessment.

The USPSTF recognizes that analytic decisions absorb added considerations than affirmation alone. Clinicians should accept the affirmation but individualize accommodation authoritative to the specific accommodating or situation. Similarly, the USPSTF addendum that action and advantage decisions absorb considerations in accession to the affirmation of analytic allowances and harms.

Summary of Recommendations and Evidence

The USPSTF recommends adjoin screening with comatose or exercise electrocardiography (ECG) to anticipate cardiovascular ache (CVD) contest in asymptomatic adults at low blow of CVD contest (D recommendation) (Figure 1).

The USPSTF concludes that the accepted affirmation is bereft to appraise the antithesis of allowances and harms of screening with comatose or exercise ECG to anticipate CVD contest in asymptomatic adults at average or aerial blow of CVD events. (I statement)

See the Analytic Considerations breadth for suggestions for convenance apropos the I statement.

Cardiovascular disease, which encompasses atheroscl altitude such as coronary affection disease, cerebrovascular disease, and borderline arterial disease, is the best accepted account of afterlife amid adults in the United States. Assay to anticipate CVD contest by modifying blow factors is currently a by CVD blow appraisal with accoutrement such as the Framingham Blow Score or the Pooled Accomplice Equations, which coat abandoned blow to acquaint assay decisions. If complete CVD blow appraisal accoutrement could be improved, assay ability be bigger targeted, thereby maximizing the allowances of and aspersing the harms of screening.

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ACSM Risk Factor Identification and Risk Stratification – PDF – acsm risk stratification form | acsm risk stratification form

The USPSTF begin bare affirmation to actuate whether abacus comatose or exercise ECG to accepted blow agency appraisal leads to bigger blow stratification of bodies to acquaint assay decisions.

Allowances of Aboriginal Apprehension and Intervention and Treatment

The USPSTF begin bare affirmation to actuate whether the incremental admonition offered by comatose or exercise ECG (beyond that acquired with acceptable CVD blow factors) can be acclimated to adviser assay decisions and ultimately abate CVD events.

Based on the epidemiology and accustomed history of CVD and accustomed assay strategies based on blow stratification, it is absurd that the allowances of screening with comatose or exercise ECG in asymptomatic adults at low blow of CVD contest are greater than small.

See the Analytic Considerations breadth for analogue of blow categories and appraisal of risk.

Harms of Aboriginal Apprehension and Intervention and Treatment

The USPSTF begin able affirmation that screening with comatose or exercise ECG in asymptomatic adults leads to harms that are at atomic baby and may be moderate, including accidental invasive procedures, overtreatment, and labeling.

The USPSTF concludes with abstinent authoritativeness that the abeyant harms of screening with comatose or exercise ECG to anticipate CVD contest according or beat the abeyant allowances in asymptomatic adults at low blow of CVD events.

The USPSTF concludes that the accepted affirmation is bereft to appraise the antithesis of allowances and harms of screening with comatose or exercise ECG to anticipate CVD contest in asymptomatic adults at average or aerial blow of CVD events.

Accommodating Citizenry Beneath Consideration

This advocacy applies to adults afterwards affection of or a assay of CVD (Figure 2).

Suggestions for Convenance Apropos the I Statement

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Acsm Risk Stratification form Beautiful Exercise is Medicine .. | acsm risk stratification form

In chief whether to awning with comatose or exercise ECG in asymptomatic adults at average or aerial blow of CVD events, clinicians should accede the afterward information.

Abeyant Preventable Burden

Although affirmation is bereft to actuate whether screening with ECG in adults is beneficial, those who may be at added blow of CVD contest ability accept the greatest abeyant for net benefit. Reclassification into a higher-risk class ability beforehand to added accelerated medical administration that could lower the blow of CVD contest but ability additionally aftereffect in harms, including adverse medication furnishings such as gastrointestinal bleeding and hepatic injury. Behindhand of ECG findings, bodies who are already at aerial blow of CVD contest should accept accelerated blow agency modification. Bodies who are classified as low blow are absurd to account from screening with ECG.

For bodies in assertive occupations, such as pilots and operators of abundant equipment, for whom abrupt awkwardness or afterlife may endanger the assurance of others, considerations added than the bloom account to the accommodating may admission the accommodation to awning with ECG to anticipate CVD events.

In all blow groups, an aberrant ECG award (a true-positive or false-positive result) can beforehand to invasive acknowledging testing and assay that accept the abeyant for austere harm, including accidental radiation exposure. Two studies of asymptomatic adults with diabetes appear that 6% and 12% of patients who were buried with exercise ECG afterwards underwent angiography, and 3% to 5% underwent revascularization, afterwards affirmation of account to the abstraction patients.1,2 Angiography and revascularization are associated with harms, including bleeding, contrast-induced nephropathy, cardiac arrhythmia, stroke, myocardial infarction, coronary avenue dissection, allergic acknowledgment to the adverse agent, and death.

Although abounding guideline groups acclaim cardiovascular blow assessment, there are few abstracts on how this is activated in analytic practice. Alone 41% of respondents in a assay of added than 900 US clinicians appear application cardiovascular blow anticipation equations in practice.3 There are few abstracts on the use of ECG to appraise CVD blow in asymptomatic patients in the United States. A Canadian attendant accomplice abstraction from 2010 to 2015 begin that 21.5% of low-risk primary affliction patients had an ECG aural 30 canicule of an anniversary bloom examination, and the admeasurement of patients who had an ECG ranged above clinics from 1.8% to 76.1%.4

Accurate identification of bodies at aerial blow of CVD contest provides the befalling for added accelerated blow agency administration to abate the likelihood of such an event. In addition, anecdotic bodies at low blow may acquiesce for a abridgement in interventions amid patients not acceptable to account from them.

Several factors are associated with an added blow of CVD events, including beforehand age, macho , aerial claret pressure, accepted smoking, aberrant lipid levels, diabetes, obesity, and concrete inactivity. Blow factors are accumulated in abounding means to appraisal a person’s blow of a CVD event. Several calculators and models are accessible to quantify a person’s 10-year blow of CVD events. The Framingham Blow Score,5 based on abstracts from the Framingham Affection Study, was one of the aboriginal broadly acclimated CVD blow appraisal tools. Bodies with a 10-year CVD blow accident greater than 20% are about advised aerial risk, those with a 10-year CVD blow accident beneath than 10% are advised low risk, and those with a 10-year CVD blow accident of 10% to 20% are advised average risk. The Pooled Accomplice Equations, alien by the American College of Cardiology and American Affection Affiliation in 2013, accommodate the aforementioned variables as the Framingham Blow Score as able-bodied as race/ethnicity and diabetes. Bodies with a 10-year CVD blow accident beneath than 7.5% are advised at low risk, and those with a 10-year CVD blow accident of 7.5% or greater are advised at animated risk.6 The USPSTF recommends that clinicians use the Pooled Accomplice Equations to appraise CVD risk.

Both comatose and exercise ECG are acclimated for the analytic appraisal of doubtable CVD, which has led to the advancement that ECG could additionally be acclimated to awning asymptomatic bodies to analyze those who would account from earlier, added accelerated administration of adjustable blow factors, antitoxin interventions, or both. Comatose ECG annal cardiac electrical action while the accommodating is at rest, over a abbreviate aeon of time. Standard ECG testing is performed with 12 leads, although some tests use beneath leads. Added recently, ECG leads accept been congenital into claret burden cuffs, smartphones, and added devices. Exercise ECG annal cardiac electrical action during concrete exertion, about at a prespecified acuteness level. The best accepted adjustment of exercise ECG is the treadmill test, but added methods, such as those application bicycles and ergometers, accept additionally been used. Both comatose and exercise ECG attending for markers of antecedent myocardial infarction, myocardial ischemia, and added cardiac abnormalities (such as larboard ventricular hypertrophy, array annex block, or arrhythmia) that may be associated with CVD or adumbrate approaching CVD events.

Assay and Interventions

Asymptomatic adults at added blow of CVD contest are usually advised with a aggregate of diet and exercise modifications, lipid-lowering medications, aspirin, hypertension management, and interventions to animate tobacco cessation. Recommendations for diet and exercise modifications, lipid-lowering medications, and aspirin are based on akin of cardiovascular risk. Contempo guidelines additionally acclaim blow stratification of hypertension treatment7; the advocacy for tobacco abeyance applies to all bodies behindhand of CVD risk.

The USPSTF has fabricated recommendations on abounding factors accompanying to CVD prevention, including screening for aerial claret pressure,8 use of statins,9 counseling on smoker cessation,10 and counseling to beforehand benign diet and concrete activity.11 In addition, the USPSTF recommends low-dose aspirin use in assertive bodies at added blow of CVD events.12

acsm risk stratification form - Heart.impulsar
acsm risk stratification form – Heart.impulsar | acsm risk stratification form

Other assets are additionally accessible from the National Heart, Lung, and Claret Institute13; Centers for Ache Control and Prevention14; and Healthy People 2020.15

A ample cardinal of studies accept appear hazard ratios and added measures of affiliation amid ECG changes and cardiovascular outcomes, so added studies of this attributes are absurd to beforehand the field. Studies are bare that appraise the incremental amount of abacus ECG to accepted CVD blow appraisal accoutrement or instruments to anon acquaint accommodation making; studies that appraise accommodating outcomes would be best useful. Failing that, studies are bare that appraise the added amount of ECG for blow reclassification above clinically accordant blow thresholds. Any abstraction of CVD blow appraisal should additionally appraise the harms associated with appraisal as able-bodied as those accompanying to added testing and treatment. Studies that admeasurement blow reclassification should address total, event, and nonevent Net Reclassification Indices, with agnate aplomb intervals, as able-bodied as measures of arrangement and discrimination.

Cardiovascular ache is the best accepted account of afterlife amid adults in the United States, accounting for 1 in 3 deaths. Although CVD charcoal a cogent account of affliction and death, bloodshed from CVD has been abbreviating over time in the United States. Currently, the anniversary blow of new cases of myocardial infarction and bookish vascular blow in the United States is 580 000 and 610 000, respectively.16

In 2012, the USPSTF recommended adjoin screening for coronary affection ache with ECG in low-risk adults (D recommendation) and issued an I account for intermediate- and high-risk adults.17 To amend the above-mentioned recommendations, the USPSTF requested the accepted affirmation review.18,19 In acceptance of how the acreage has advanced, the accepted affirmation assay did not accommodate affiliation studies but addressed whether the accession of screening with comatose or exercise ECG improves bloom outcomes compared with acceptable CVD blow appraisal in asymptomatic adults.

Accurateness of Screening Tests

The USPSTF advised the affirmation on whether screening with comatose or exercise ECG improves calibration, discrimination, or blow reclassification back added to CVD blow appraisal models application acceptable blow factors. The USPSTF focused on affirmation that ECG adds to accepted CVD blow appraisal with the Framingham Blow Score or the Pooled Accomplice Equations, because this could beforehand to change in treatments for patients.

The USPSTF articular 5 accomplice studies (2 of which overlap with the antecedent review) that evaluated whether abacus exercise ECG to accepted CVD blow appraisal models improves calibration, discrimination, or reclassification. Four studies adjourned whether exercise ECG bigger calibration; 2 studies evaluated abacus exercise ECG to the Framingham Blow Score,20,21 and the added 2 studies evaluated abacus exercise ECG to added blow appraisal models.22,23 The studies acclimated altered measures and showed alloyed furnishings on calibration. Three studies adjourned whether abacus exercise ECG to the Framingham Blow Score21 or added blow appraisal models22,24 bigger discrimination, and all begin alone baby complete improvements in breadth beneath the ambit or C accomplishment (0.02-0.03). Alone 1 blow appraisal archetypal development abstraction evaluated whether abacus exercise ECG bigger blow reclassification. However, the abstraction did not administer blow thresholds that currently actuate assay and alone appear all-embracing reclassification, not blow and nonevent net reclassification.22

The USPSTF articular 9 accomplice studies (1 of which overlapped with the antecedent review) that evaluated whether abacus comatose ECG to accepted CVD blow appraisal models improves calibration, discrimination, or reclassification; 5 of these studies evaluated assorted ECG changes and 4 evaluated a distinct ECG change. Five studies evaluated abacus comatose ECG to the Framingham Blow Score,25-29 and 1 of these studies29 additionally evaluated abacus comatose ECG to the Pooled Accomplice Equations. Abacus comatose ECG to complete CVD blow appraisal models bigger arrangement for several CVD outcomes, although the backbone of affirmation was low and resulted in baby or actual baby improvements in bigotry (absolute advance in breadth beneath the ambit or C statistic, 0.001-0.050). Two studies appear net reclassification back comatose ECG was added to the Framingham Blow Score,18,26,27 and 1 study29 evaluated abacus comatose ECG to both the Framingham Blow Score and the Pooled Accomplice Equations. There was a baby to abstinent advance in reclassification but the studies did not present the abounding reclassification data, so it is difficult to actuate whether the reclassification would change treatment. No 2 studies evaluated the aforementioned CVD blow appraisal model, blow class threshold, or outcome.

Capability of Aboriginal Apprehension and Treatment

The USPSTF articular no studies that anon adjourned whether abacus comatose ECG to accepted CVD blow appraisal models improves cardiovascular outcomes for any blow group.18,19 The USPSTF articular 2 fair-quality randomized analytic trials of screening with exercise ECG in bodies with diabetes (and accordingly at added blow of CVD) that begin no aberration in bloodshed or cardiovascular events.1,2 However, both trials fell far abbreviate of their advised acceptance and accordingly were underpowered and had a almost abbreviate time aeon (mean, 3.5 years) to ascertain a aberration in cardiovascular outcomes.

Abeyant Harms of Screening and Treatment

Resting ECG has the abeyant for all-overs and labeling; however, the USPSTF was clumsy to acquisition accordant studies on these harms. Exercise ECG has added abeyant for absolute harms (eg, triggering a cardiovascular blow or musculoskeletal injury), but assay abstracts of adapted patients suggests that these harms are actual rare.30,31 The primary affair for both types of ECG screening is the abuse of consecutive procedures or interventions accomplished as a aftereffect of screening (eg, angiography or revascularization procedures). Alone 1 abstraction appear harms of consecutive testing (1/12 patients referred for revascularization had a nonfatal myocardial infarction)2; therefore, the USPSTF included a broader ambit of abstraction designs in its appraisal to appraisal abeyant harms.

Applying Risk Classification as a Fitness Professional - acsm risk stratification form
Applying Risk Classification as a Fitness Professional – acsm risk stratification form | acsm risk stratification form

Angiography ante afterwards screening with exercise ECG in asymptomatic populations are about beneath than 3% (range, 0.6%-13%). The majority of patients ability angiography in these studies did not accept angiographically ascertainable coronary avenue stenosis, but some did abide revascularization (0.1%-0.5%).18 Based on ample population-based registries that accommodate adapted persons, angiography is associated with a austere abuse amount of 1.7%, including arrhythmia (0.40%), afterlife (0.10%), achievement (0.07%), and myocardial infarction (0.05%). Revascularization increases the blow of periprocedural myocardial infarction (1.7%), coronary avenue anatomization (1.3%), bleeding contest aural 72 hours (1.3%), vascular complications (0.4%), renal abortion (0.4%), achievement (0.1%), and afterlife on day of action (<0.01%).18 The USPSTF did not acquisition any contempo studies that anon addressed the abeyant harms of all-overs or labeling.

Appraisal of Magnitude of Net Benefit

For asymptomatic adults at low blow of CVD contest (defined as 10-year CVD blow accident <10%), it is actual absurd that the admonition from comatose or exercise ECG (beyond that acquired with accepted CVD blow factors) will aftereffect in a change in the patient’s blow class that would beforehand to a change in assay and ultimately beforehand bloom outcomes. Austere accessible harms are associated with screening with comatose or exercise ECG, accurately the abeyant adverse furnishings of consecutive invasive testing. Therefore, the USPSTF concludes with abstinent authoritativeness that screening with ECG in asymptomatic adults at low blow of CVD contest has no net benefit.

For asymptomatic adults at average or aerial blow of CVD contest (defined as a 10-year CVD blow accident of 10%-20% or >20%, respectively), there is bereft affirmation to actuate the admeasurement to which admonition from comatose or exercise ECG adds to accepted CVD blow appraisal models (ie, Pooled Accomplice Equations) and whether it after-effects in a change in blow administration and ultimately reduces CVD events. As with low-risk adults, austere accessible harms are associated with screening with comatose or exercise ECG in asymptomatic adults at average or aerial blow of CVD events. The USPSTF concludes that there is bereft affirmation to appraisal the net account of screening with ECG in asymptomatic adults at average or aerial blow of CVD events.

How Does Affirmation Fit With Biological Understanding?

There is abundant and constant affirmation that anecdotic and alleviative traditional, adjustable CVD blow factors such as aerial claret pressure, aberrant lipid levels, diabetes, accepted smoking, concrete inactivity, and diet beforehand cardiovascular outcomes. These blow factors are affiliated to the biological compassionate of the pathophysiology of CVD. Electrocardiography measures the electrical action in the affection and after-effects can be aberrant for abounding reasons, alone some of which are attributable to atheroscl CVD. In low-risk patients, these abnormalities are absurd to aftereffect from atheroscl CVD; in intermediate- and high-risk patients, they are added acceptable to aftereffect from atheroscl CVD, but there is no affirmation that targeting these abnormalities in accession to adjustable blow factors has benefit.

Acknowledgment to Accessible Comment

A abstract adaptation of this advocacy account was acquaint for accessible animadversion on the USPSTF website from December 19, 2017, to January 22, 2018. In acknowledgment to accessible comments, the USPSTF antiseptic the analogue of CVD and the adopted CVD blow appraisal tool.

Amend of Antecedent USPSTF Recommendation

This advocacy is an amend of the 2012 USPSTF recommendation. As in 2012, the USPSTF continues to acclaim adjoin screening with ECG in adults at low risk, and the affirmation charcoal bereft on screening in adults at added risk.17

Recommendations of Others

The American College of Physicians recommends adjoin screening for CVD with comatose or accent ECG in asymptomatic, low-risk adults.32 The American College of Cardiology concludes that exercise ECG is rarely adapted in asymptomatic adults at low all-around blow of CVD events, may be an adapted advantage for adults at average risk, and is adapted for adults at aerial risk.33 In 2012, the American Academy of Family Physicians recommended adjoin screening with ECG in asymptomatic, low-risk persons.34 The American College of Antitoxin Medicine recommends adjoin commonly screening with comatose or exercise ECG in the accepted developed population.35

acsm risk stratification form - Heart.impulsar
acsm risk stratification form – Heart.impulsar | acsm risk stratification form

Corresponding Author: Susan J. Curry, PhD, University of Iowa, 111 Jessup Hall, Iowa City, IA 52242 ([email protected]).

Accepted for Publication: May 2, 2018.

The US Antitoxin Casework Task Force (USPSTF) members: Susan J. Curry, PhD; Alex H. Krist, MD, MPH; Douglas K. Owens, MD, MS; Michael J. Barry, MD; Aaron B. Caughey, MD, PhD; Karina W. Davidson, PhD, MASc; Chyke A. Doubeni, MD, MPH; John W. Epling Jr, MD, MSEd; Alex R. Kemper, MD, MPH, MS; Martha Kubik, PhD, RN; C. Seth Landefeld, MD; Carol M. Mangione, MD, MSPH; Michael Silverstein, MD, MPH; Melissa A. Simon, MD, MPH; Chien-Wen Tseng, MD, MPH, MSEE; John B. Wong, MD.

Affiliations of The US Antitoxin Casework Task Force (USPSTF) members: University of Iowa, Iowa City (Curry); Fairfax Family Convenance Residency, Fairfax, Virginia (Krist); Virginia Commonwealth University, Richmond (Krist); Veterans Affairs Palo Alto Bloom Affliction System, Palo Alto, California (Owens); Stanford University, Stanford, California (Owens); Harvard Medical School, Boston, Massachusetts (Barry); Oregon Bloom & Science University, Portland (Caughey); Columbia University, New York, New York (Davidson); University of Pennsylvania, Philadelphia (Doubeni); Virginia Tech Carilion School of Medicine, Roanoke (Epling); Nationwide Children’s Hospital, Columbus, Ohio (Kemper); Temple University, Philadelphia, Pennsylvania (Kubik); University of Alabama at Birmingham (Landefeld); University of California, Los Angeles (Mangione); Boston University, Boston, Massachusetts (Silverstein); Northwestern University, Evanston, Illinois (Simon); University of Hawaii, Honolulu (Tseng); Pacific Bloom Analysis and Education Institute, Honolulu, Hawaii (Tseng); Tufts University, Medford, Massachusetts (Wong).

Author Contributions: Dr Curry had abounding admission to all of the abstracts in the abstraction and takes albatross for the candor of the abstracts and the accurateness of the abstracts analysis. The USPSTF associates contributed appropriately to the advocacy statement.

Conflict of Absorption Disclosures: All authors accept completed and submitted the ICMJE Form for Disclosure of Abeyant Conflicts of Interest. Authors followed the action apropos conflicts of absorption declared at https://www.uspreventiveservicestaskforce.org/Page/Name/conflict-of-interest-disclosures. All associates of the USPSTF accept biking agreement and an honorarium for accommodating in USPSTF meetings. No added disclosures were reported.

Funding/Support: The USPSTF is an independent, autonomous body. The US Congress mandates that the Agency for Healthcare Analysis and Quality (AHRQ) abutment the operations of the USPSTF.

Role of the Funder/Sponsor: AHRQ agents assisted in the following: development and assay of the analysis plan, agency of the analytical affirmation assay from an Evidence-based Convenance Center, allocation of able assay and accessible animadversion of the abstract affirmation address and abstract advocacy statement, and the autograph and alertness of the final advocacy account and its acquiescence for publication. AHRQ agents had no role in the approval of the final advocacy account or the accommodation to abide for publication.

Disclaimer: Recommendations fabricated by the USPSTF are absolute of the US government. They should not be construed as an official position of AHRQ or the US Department of Bloom and Human Services.

Additional Contributions: We acknowledge Howard Tracer, MD, and Elizabeth Kato, MD, MRP (AHRQ), who contributed to the autograph of the manuscript, and Lisa Nicolella, MA (AHRQ), who assisted with allocation and editing.

Jonas  DE, Reddy  S, Middleton  JC,  et al.  Screening for Cardiovascular Ache Blow With Electrocardiography: An Affirmation Assay for the U.S. Antitoxin Casework Task Force: Affirmation Synthesis No. 163. Rockville, MD: Agency for Healthcare Analysis and Quality; 2018. AHRQ advertisement 17-05235-EF-1.

American College of Sports Medicine.  ACSM’s Guidelines for Exercise Testing and Prescription. 10th ed. Philadelphia, PA: Wolters Kluwer; 2017.

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Applying Risk Classification as a Fitness Professional – acsm risk stratification form | acsm risk stratification form

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