Supervision of Exercise Testing by Nonphysicians

Myers, Jonathan; Forman, Daniel E.; Balady, Gary J.; Franklin, Barry A.; Nelson-Worel, Jane; Martin, Billie Jean; Herbert, William G.; Guazzi, Marco; Arena, Ross

doi:10.1161/cir.0000000000000101

Cited by 97 publications

(31 citation statements)

References 51 publications

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“…2 Recommendations for performance of exercise testing by nonphysicians (clinical exercise physiologists, registered nurses, nurse practitioners, physician assistants, and physical therapists) as well as the role of supervising physician have been published recently. 3 Recommendations for testing specific populations [women, older adults, asymptomatic patients, prior to noncardiac surgery and exercise testing combined with cardiopulmonary exercise testing (CPET)] can be found in the following documents:…”

Section: Exercise Testingmentioning

confidence: 99%

ASNC imaging guidelines for SPECT nuclear cardiology procedures: Stress, protocols, and tracers

Henzlova

Duvall

Einstein

et al. 2016

Journal of Nuclear Cardiology

529

386

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Section: Exercise Testingmentioning

confidence: 99%

ASNC imaging guidelines for SPECT nuclear cardiology procedures: Stress, protocols, and tracers

Henzlova

Duvall

Einstein

et al. 2016

Journal of Nuclear Cardiology

529

386

View full text Add to dashboard Cite

“…As noted in numerous recent American Heart Association scientific statements, the measurement of CRF in clinical settings is both important and feasible. 74,75,152,153,292 Additionally, estimates of CRF using nonexercise algorithms have pragmatic importance and provide values for CRF that enhance risk prediction when direct CRF measures are not feasible. In fact, routine estimation of CRF in clinical practice is CRF indicates cardiorespiratory fitness; CVD, cardiovascular disease; HRR, heart rate reserve; MET, metabolic equivalents; and V no more difficult than measuring blood pressure, and procedures for incorporating CRF estimation into routine clinical assessments in a pragmatic manner are provided in Tables 9 and 10.…”

Section: Discussionmentioning

confidence: 99%

“…74 A major hurdle to performing CPX in the clinical setting was cleared with the recent recommendation that most maximal exercise tests can be supervised by appropriately trained nonphysician health professionals. 153 In many patient populations, considerable evidence now indicates that the added value of the unique clinical information obtained by CPX is clearly justified.…”

Section: Crf and Disabilitymentioning

confidence: 99%

Importance of Assessing Cardiorespiratory Fitness in Clinical Practice: A Case for Fitness as a Clinical Vital Sign: A Scientific Statement From the American Heart Association

Ross¹,

Blair²,

Arena³

et al. 2016

Circulation

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1,770

1,697

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ABSTRACT:Mounting evidence has firmly established that low levels of cardiorespiratory fitness (CRF) are associated with a high risk of cardiovascular disease, all-cause mortality, and mortality rates attributable to various cancers. A growing body of epidemiological and clinical evidence demonstrates not only that CRF is a potentially stronger predictor of mortality than established risk factors such as smoking, hypertension, high cholesterol, and type 2 diabetes mellitus, but that the addition of CRF to traditional risk factors significantly improves the reclassification of risk for adverse outcomes. The purpose of this statement is to review current knowledge related to the association between CRF and health outcomes, increase awareness of the added value of CRF to improve risk prediction, and suggest future directions in research. Although the statement is not intended to be a comprehensive review, critical references that address important advances in the field are highlighted. The underlying premise of this statement is that the addition of CRF for risk classification presents health professionals with unique opportunities to improve patient management and to encourage lifestyle-based strategies designed to reduce cardiovascular risk. These opportunities must be realized to optimize the prevention and treatment of cardiovascular disease and hence meet the American Heart Association's 2020 goals.M ounting evidence over the past 3 decades has firmly established that low levels of cardiorespiratory fitness (CRF) are associated with a high risk of cardiovascular disease (CVD) and all-cause mortality, as well as mortality rates attributable to various cancers, especially of the breast and colon/digestive tract. [1][2][3][4] Importantly, improvements in CRF are associated with reduced mortality risk.5 Although CRF is now recognized as an important marker of cardiovascular health, it is currently the only major risk factor not routinely assessed in clinical practice.In 2013, the American Heart Association and the American College of Cardiology jointly released new guidelines for the prevention and treatment of coronary artery disease.6 Although CRF is the fourth-leading risk factor for CVD and has long been established as a significant prognostic marker, 7 it was excluded from the risk calculator. The authors of the guidelines noted that the evidence that CRF would enhance risk classification was inconclusive, and thus, the added contribution of CRF to determine CVD risk was uncertain. There is, however, a large body of epidemiological and clinical evidence demonstrating not only that CRF is a potentially stronger predictor of mortality than established risk factors such as smoking, hypertension, high cholesterol, and type 2 diabetes mellitus (T2DM), but that the addition of CRF to traditional risk factors significantly improves the reclassification of risk for adverse outcomes.

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“…This concept is reinforced by various American Heart Association statements attesting to the capacities of many allied providers to perform exercise testing. 11 Nonetheless, for patients with known cardiac disease, current standards still assert the primary leadership and availability of a cardiologist as a fundamental standard of maximal stress testing. 11 Thus, whether a maximum exercise test is physically administered by an exercise physiologist or other nonphysician, it still remains linked to the availability of a physician, thereby creating logistic complexities.…”

Section: Conceptual Value Versus the Conundrums Of Clinical Practicementioning

confidence: 99%

“…11 Nonetheless, for patients with known cardiac disease, current standards still assert the primary leadership and availability of a cardiologist as a fundamental standard of maximal stress testing. 11 Thus, whether a maximum exercise test is physically administered by an exercise physiologist or other nonphysician, it still remains linked to the availability of a physician, thereby creating logistic complexities. done by CR staff with little or no additional costs beyond standard CR fees, and without scheduling intricacies.…”

Section: Conceptual Value Versus the Conundrums Of Clinical Practicementioning

confidence: 99%

Evolving Role of Exercise Testing in Contemporary Cardiac Rehabilitation

Reeves

Gupta

Forman

2016

Journal of Cardiopulmonary Rehabilitation and Prevention

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Symptom-limited (maximal) exercise testing before cardiac rehabilitation (CR) was once an unambiguous standard of care. In particular, it served as an important screen for residual ischemia and instability before initiating a progressive exercise training regimen. However, improved revascularization and therapy for coronary heart disease has led many clinicians to downplay this application of exercise testing, especially because such testing is also a potential encumbrance to CR enrollment (delaying ease and efficiency of enrollment after procedures and hospitalizations) and patient burden (eg, added costs, logistic hassle, and anxiety). Nonetheless, exercise testing has enduring value for CR, especially because it reveals dynamic physiological responses as well as ischemia, arrhythmias, and symptoms pertinent to exercise prescription and training and to overall stability and prognosis. Moreover, as indications for CR have expanded, the value of exercise testing and functional assessment is more relevant than ever in the growing population of eligible patients, including those with heart failure, valvular heart disease, and posttransplantation, especially as current patients also tend to be more clinically complex, with advanced ages, multimorbidity, frailty, and obesity. This review focuses on the appropriate use of exercise testing in the CR setting. Graded exercise tests, cardiopulmonary exercise tests, submaximal walking tests, and other functional assessments (strength, frailty) for CR are discussed.

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Supervision of Exercise Testing by Nonphysicians

Cited by 97 publications

References 51 publications

ASNC imaging guidelines for SPECT nuclear cardiology procedures: Stress, protocols, and tracers

ASNC imaging guidelines for SPECT nuclear cardiology procedures: Stress, protocols, and tracers

Importance of Assessing Cardiorespiratory Fitness in Clinical Practice: A Case for Fitness as a Clinical Vital Sign: A Scientific Statement From the American Heart Association

Evolving Role of Exercise Testing in Contemporary Cardiac Rehabilitation

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