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Everything You Need To Know About Risk Stratification

Everything You Need To Know About Risk Stratification  | Bindi Delaney | Exam Preparation Blog | 8/30/2013


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Risk stratificationRisk stratification is an important health assessment that all fitness professionals should be familiar with. It is a systematic screening from the American College of Sports Medicine (ACSM) that addresses signs and symptoms of heart disease, risk factors for heart disease and family history.

Risk Stratification is determined by adding up the points as indicated here and comparing what actions are recommended based on that score.

CVD Risk Stratification Criteria:

For each risk the client has you add a +1.

For HDL cholesterol (good cholesterol) there is an opportunity to take away a risk if the level is high.

Client Age: Male > 45, Female > 55
Family History: Major heart condition (heart attack, bypass surgery) for the client’s father who is younger than 55 years old or mother who is younger than 65 years old
Cigarette smoking: Client currently smokes or quit within the last six months
Sedentary lifestyle: Does not complete 30 minutes of moderate exercise on at least three days for at least three months (think the 3, 3’s!)
Obesity: Client has a BMI greater than 30
Hypertension: Blood pressure of 140/90 or higher
Cholesterol: Total cholesterol should only be used if it is the only value given. If using total, greater than 200mg/dL is considered a risk.
If you are given LDL and HDL cholesterol, use these values only.
LDL (bad cholesterol) greater than 130mg/dL is a risk
HDL (good cholesterol, you want lots) less than 40mg/dL is a risk.
HDL (good cholesterol) greater than 60mg/dL is good, allowing an individual to take a risk away (-1)
PreDiabetes: Fasting glucose is greater than 100mg/dL is a risk

The risks are then totaled and the client is placed in one of the risk categories:

LOW risk = 1 or fewer risks
MODERATE risk = 2 or more risks
HIGH risk = Symptomatic (see signs and symptoms below) or if the client has a known cardiac, pulmonary or metabolic disease

Signs and Symptoms:
Pain (tightness) or discomfort in the chest, neck, jaw, arms or other areas that may result from ischemia, shortness of breath, or difficulty breathing at rest or with mild exertion (dyspnea), orthopnea (dyspnea in a reclined position), ankle edema, palpitations or tachycardia, intermittent claudication (pain sensations or cramping in the lower extremities associated with inadequate blood supply), known heart murmur, unusual fatigue or difficulty breathing with usual activities, and dizziness or syncope, most commonly caused by reduced perfusion to the brain.

It is important to complete a risk stratification because it determines whether the client needs to be reffered to a doctor before moderate and/or vigourous exercise.

Consider the following Case Studies to see if you are on the right track. The correct answers are listed below. You may also like to visit our Study Center Facebook page where additional risk stratification examples are posted as study tips.

Client 1
Client: Male, age = 42 years
Family history: Father was diagnosed with hypertension at 54 years of age
Smoking: Quit smoking 4 years ago
BMI: 29 kg/m2
Blood pressure: 140/86 mmHg
Total serum cholesterol: 220 mg/dL
Fasting plasma glucose: 98 mg/dL
Current exercise: Has walked at a leisurely pace for 15 minutes each day for the last 2 years

Client 2
Client: Female, age = 56 years
Family history: Mother has diabetes, father had a heart attack at age 57
Smoking: Non-smoker
Height: 70 in (1.78 m)
Weight: 195 lb (88.6 kg)
BMI: 28 kg/m2
Blood pressure: 119/79 mmHg
LDL cholesterol: 115 mg/dL
HDL cholesterol: 64 mg/dL
Fasting plasma glucose: 90 mg/dL
Current exercise: Has attended a weekly yoga class for the past 6 months

Client 3
Client: Male, age = 40 years
Family history: Mother had bypass surgery at age 60
Client health history: Known heart murmur
Smoking: Non-smoker
BMI: 25 kg/m2
Blood pressure: 120/81 mmHg
Total serum cholesterol: 224 mg/dL
LDL cholesterol: 126 mg/dL
HDL cholesterol: 51 mg/dL
Fasting plasma glucose: 82 mg/dL
Current exercise: Attends 4 hour-long resistance-training classes per week and has completed half marathon running, regularly training 7+ hours a week for the past year

You can find additional information about risk stratification in all four ACE manuals: Group Fitness Instructor, Personal Trainer, Health Coach and Advanced Health & Fitness Specialist.


Client 1: +3 risks = moderate risk = +1 for blood pressure, +1 for total cholesterol, +1 for sedentary lifestyle

Client 2: +1 risk = low risk = +1 risk = +1 for age, +1 for sedentary lifestyle, -1 for HDL cholesterol

Client 3: = High risk – known heart murmur