The purpose of this report is to provide revised standards and guidelines for the exercise testing and training of individuals who are free from clinical manifestations of cardiovascular disease and those with known cardiovascular disease. These guidelines are intended for physicians, nurses, exercise physiologists, specialists, technologists, and other healthcare professionals involved in exercise testing and training of these populations. This report is in accord with the “Statement on Exercise” published by the American Heart Association (AHA).1

These guidelines are a revision of the 1995 standards of the AHA that addressed the issues of exercise testing and training.2 An update of background, scientific rationale, and selected references is provided, and current issues of practical importance in the clinical use of these standards are considered. These guidelines are in accord with the American College of Cardiology (ACC)/AHA Guidelines for Exercise Testing.3

### The Cardiovascular Response to Exercise

Exercise, a common physiological stress, can elicit cardiovascular abnormalities that are not present at rest, and it can be used to determine the adequacy of cardiac function. Because exercise is only one of many stresses to which humans can be exposed, it is more appropriate to call an exercise test exactly that and not a “stress test.” This is particularly relevant considering the increased use of nonexercise stress tests.

### Types of Exercise

Three types of muscular contraction or exercise can be applied as a stress to the cardiovascular system: isometric (static), isotonic (dynamic or locomotory), and resistance (a combination of isometric and isotonic).4,5 Isotonic exercise, which is defined as a muscular contraction resulting in movement, primarily provides a volume load to the left ventricle, and the response is proportional to the size of the working muscle mass and the intensity of exercise. Isometric exercise is defined as a muscular contraction without movement (eg, handgrip) and imposes greater pressure than volume …

Exercise Standards for Testing and Training A Scientific Statement From the American Heart Association

Cardiovascular diseases (CVD) are the leading cause of morbidity and mortality in the United States.1 Primary prevention and secondary prevention of CVD are public health priorities.2 Substantial data indicate that CVD is a life course disease that begins with the evolution of risk factors that in turn contribute to the development of subclinical atherosclerosis.3,4 Subclinical disease culminates in overt CVD.5,6 The onset of CVD itself portends an adverse prognosis with greater risk of recurrent events, morbidity, and mortality.7,8 It is also increasingly clear that although clinical assessment is the keystone of patient management, such evaluation has its limitations.9–12 Clinicians have used additional tools to aid clinical assessment and to enhance their ability to identify the “vulnerable” patient at risk for CVD, as suggested by a recent National Institutes of Health (NIH) panel.13,14 Biomarkers are one such tool to better identify high-risk individuals, to diagnose disease conditions promptly and accurately, and to effectively prognosticate and treat patients with disease. This review provides an overview of the molecular basis of biomarker discovery and selection and the practical considerations that are a prerequisite to their clinical use.

The term biomarker (biological marker) was introduced in 1989 as a Medical Subject Heading (MeSH) term: “measurable and quantifiable biological parameters (eg, specific enzyme concentration, specific hormone concentration, specific gene phenotype distribution in a population, presence of biological substances) which serve as indices for health- and physiology-related assessments, such as disease risk, psychiatric disorders, environmental exposure and its effects, disease diagnosis, metabolic processes, substance abuse, pregnancy, cell line development, epidemiologic studies, etc.” In 2001, an NIH working group standardized the definition of a biomarker as “a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a therapeutic intervention” …

Biomarkers of cardiovascular disease: molecular basis and practical considerations.

http://cardiology.org/recentpapers/sumetgl02.pdf

Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines)

At least 25% of coronary patients have sudden death or nonfatal myocardial infarction without prior symptoms1 Therefore, the search for coronary patients with subclinical disease who could potentially benefit from intensive primary prevention efforts is critically important The American Heart Association’s (AHA) Prevention V Conference, “Beyond Secondary Prevention: Identifying the High Risk Patient for Primary Prevention,” addressed ways to identify more patients who are asymptomatic and clinically free of coronary heart disease (CHD) but at sufficiently high risk for a future coronary event to justify more intensive risk reduction efforts2 In this report, we amplify on key findings and recommendations of the AHA Prevention V conference, highlight new research since the conference, and propose an approach to the use of office-based testing and additional noninvasive procedures in selected patients to better define their coronary event risk The recommendations are concordant with the recently released approach to risk assessment and management from the third report of the Adult Treatment Panel of the National Cholesterol Education Program (ATP-III)3

Enthusiasm for primary prevention and risk assessment in asymptomatic people has been spurred by recent advances in prevention research Lipid-lowering trials demonstrated that primary prevention of coronary events is feasible, evidenced by the West of Scotland Coronary Primary Prevention Study (WOSCOPS) trial4 of hypercholesterolemic men and by the Air Force/Texas Coronary Atherosclerosis Prevention Study (AFCAPS/TexCAPS) trial5 in average or typical risk men and women with only moderate lipid abnormalities Aspirin6 or ACE inhibitors7 can also reduce risk in selected asymptomatic, high-risk people Emerging coronary risk factors have been described including inflammatory, infectious, and thrombotic markers,8 and there has been a steady flow of reports that focus attention on potential new ways of predicting coronary risk9 In addition, noninvasive tests for subclinical atherosclerotic disease are available …

Improving Coronary Heart Disease Risk Assessment in Asymptomatic People Role of Traditional Risk Factors and Noninvasive Cardiovascular Tests

https://www.healthmegamall.com/Articles/BabeskinArticle348.pdf

Erectile dysfunction prevalence, time of onset and association with risk factors in 300 consecutive patients with acute chest pain and angiographically documented coronary artery disease.

Prognostic value of exercise electrocardiogram in men at high risk of future coronary heart disease: Multiple risk factor intervention trial experience

William J. Eifler

Papers

Prognostic value of exercise electrocardiogram in men at high risk of future coronary heart disease: Multiple risk factor intervention trial experience

A simple procedure for positioning precordial ECG and VCG electrodes using an electrode locator.

Quality control procedures for the resting electrocardiogram in the Multiple Risk Factor Intervention Trial.

A cellular model for the simulation of activation in the ventricular myocardium.