The Process Of Risk Stratification

The purpose of the risk-stratification process is to identify all the factors related to an individual and place them in a risk category based on an increased likelihood of adverse effects. This provides the exercise leader with guidance in respect to exercise prescription, monitoring and supervision. Most risk-stratification tools classify individuals into low, medium/moderate and high risk categories. However, at this time, there would appear to be no clearly validated comprehensive risk-assessment tool for entry to the exercise component of CR. All international guidelines for CR nevertheless advocate a similar approach. Table 2.1 shows the AACVPR (2004) guidelines. Individuals who do not meet the classification for either low or high are defined as moderate or medium risk.

The summary of the 1999 Canadian Guidelines (Stone, et al., 2001) has, however, proposed three possible strategies for the risk stratification of patients entering CR programmes. One approach is based on the long-standing, traditional format, established by the AHA (2001) and the AACVPR (2004) and which classifies risk stratification into low (class A), intermediate (class B) and high risk (class C) categories. This system has been adopted by most CR professionals to date. However, it is an approach which seems to reflect sound medical judgement and evidence-based practice, but fails to take

Table 2.1. Characteristics of low and high risk CR (Adapted from the AACPR, 2004)

A low-risk individual would have all of the following:

Normal haemodynamic response to exercise and recovery No evidence of myocardial ischaemia

Normal left ventricular function

Functional capacity of 7 METs

(metabolic equivalents) or more Absence of clinical depression

A high-risk individual would have only one of the following:

Decreased left ventricular function -

ejection fraction <40% Abnormal haemodynamic response with exercise and recovery Persistent or recurrent ischaemia at low levels of exercise Functional capacity of <5 METs

Survivor of cardiac arrest or sudden death Complicated recovery post-event, i.e.

cardiogenic shock, CHF Clinically significant depression

Box 2.1 Discussion point on risk stratification

Discussion point:

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