Identify patients who have contraindications to an exercise program.

For the purpose of establishing a safe and effective exercise program, the patient should undergo a careful medical evaluation and review of the exercise test data, prior to participating in the program. The specific components of the medical evaluation should include a medical history, physical examination, and resting ECG. The exercise test should be repeated any time symptoms or clinical changes warrant and in follow-up assessment of exercise training outcomes.

Patients with the following conditions should have medical evaluation/intervention before beginning an exercise-training program:

•  Angina or other symptoms of cardiovascular insufficiency
  
•  ECG evidence of ischemia, >2 mm ST-segment depression at low level of exercise (i.e.,
   submaximal workloads)
  
•  Plateau or decrease in systolic blood pressure associated with LV dysfunction
  
•  Uncompensated heart failure
  
•  Syncope or lightheadedness during exercise
  
•  Exercise-induced ventricular tachycardia or other exercise-induced dysrhythmias causing
   symptoms
  
•  Other significant ECG disturbances (e.g., new or uncontrolled atrial fibrillation and
   supraventricular tachycardia)
  
•  Other conditions that could be aggravated by exercise (e.g., resting blood pressure >180 mm Hg
   systolic and/or >110 mm Hg diastolic, active or suspected myocarditis or pericarditis, and
   uncontrolled diabetes (i.e., exercise-induced hypoglycemia or resting blood glucose >400 mg/dl))
  
•  Other clear signs or symptoms of exercise intolerance

Maximizing medical intervention or management for these conditions is necessary. A repeat stress test is recommended at the discretion of the referring physician. In patients with maximal medical management, the peak exercise training heart rate should be set sufficiently below the heart rate that occurred at the onset of the conditions described above (refer to Table 4 in Annotation H).

Exceptions to the list of contraindications to an exercise program should be considered, based on sound clinical judgement.

Consider physical therapy consultation for design of an exercise program for patients with special orthopedic adaptations (e.g., arthritis or lower extremities amputees).