Components Of Clinical Assessment

The following section details key components of a pre-exercise assessment, but is by no means exhaustive. It describes the rationale for each component, including supporting evidence, and highlights links to the risk categories previously detailed, i.e. functional capacity, ischaemic burden, arrhythmic potential and LV function.

Assessment of the patient should include not only the risk-stratification process and establishment of functional capacity; there should also be a gathering of further information during a subjective interview.

This assessment process may take place repeatedly over the four phases of rehabilitation, with a number of factors being assessed in phase I and reassessed over time. This will give a holistic view of the patient, highlighting factors, which may influence progress, adherence or long-term behaviour change, e.g. co-morbidities, stage of change and quality of life (as seen in Table 2.2).

For patients who are unable to undertake exercise testing or for clinicians who do not have access to resources or facilities for functional capacity testing, this assessment becomes the risk-stratification tool itself. This type of holistic assessment has been developed by individual expert practitioners and refined as the specialty of CR has evolved over the last 20 years. It highlights the

Table 2.3. Exclusion criteria for exercise-based CR

Exclusion Criteria ACSM Goble and BACR Balady and

2001 Worcester 1995 Donald

1999 1991

Exclusion Criteria ACSM Goble and BACR Balady and

2001 Worcester 1995 Donald

1999 1991

Unstable angina

Resting BP >200 systolic or

>110/110 diastolic

Significant aortic stenosis

Orthostatic hypotension

Acute illness or fever/viral infection

Active peri/myocarditis

New or uncontrolled tachycardia

✓ -100 bpm


Uncompensated HF

New or uncontrolled arrhythmias -

a or v or 3rd degree block

Uncontrolled diabetes or metabolic


Severe co-morbidity preventing

participation - physical or


Recent pulmonary or other


Resting ST-segment displacement


Recent stroke, TIA

Patient or physician refusal

New or recent breathlessness,

palpitations, dizziness or lethargy

Hypertrophic cardiomyopathy

importance of high-level clinical reasoning skills (Castle, 2003) in the exercise professional and of his or her ability to apply clinical judgement to each patient.

There are numerous patient-related factors that can be included in a comprehensive multidisciplinary assessment (e.g. social support, anxiety and depression, smoking status, age, gender, etc.) of that, although not directly related to risk stratification or assessment for exercise, can have a significant effect on patient adherence or progress within a CR programme.

Prior to meeting the patient the exercise leader must ascertain the current referral for cardiac rehabilitation and exercise assessment. As the eligibility of patients with CHD has widened from post-MI and post-CABG, not all patients will undergo medical investigation prior to CR programme entry. For example, many revascularisation patients no longer have routine ETT, and it is unlikely that angina patients will receive echocardiography. The clinician, therefore, has to look for historical information to create a picture of what the ischaemic burden, arrhythmic potential and LV function may be. Key indicators would be:

• site and size of infarct

• enzyme results

• thrombolysis with ECG resolution or not

• complication during phase I, i.e. cardiogenic shock, cardiac arrest

• complicated abnormal resting ECG

• site and severity of lesions from angiography

• potential for revascularisation of lesion

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