Christopher Gagliardi by Christopher Gagliardi

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

Risk classification is determined based on the presence or absence of a known cardiovascular, pulmonary, renal, or metabolic disease or the presence or absence of symptoms of these diseases (see “Signs and Symptoms” below). Diseases are known if the client has been diagnosed by a physician. Signs and symptoms may or may not have been diagnosed by a physician. For example, “unusual fatigue or difficulty breathing with usual activities” might be a symptom that the client reports to you, but has not mentioned to his or her physician, whereas a “known heart murmur” is a sign that is only known if diagnosed by a doctor. The positive risk factor points as indicated below are used to classify individuals as low or moderate risk and determine what actions are recommended based on that risk score.

Cardiovascular Disease (CVD) Risk Stratification Criteria:

For each positive risk factor, add a +1.

For HDL cholesterol (good cholesterol) there is an opportunity to take away a risk (-1) if the level is high (≥60 mg/dL).

  • Client Age: Male  ≥45, Female ≥ 55 
  • Family History: Myocardial infarction (heart attack), coronary revascularization (bypass surgery), or sudden death for the client’s male first-degree relative who is younger than 55 years old or female first-degree relative who is younger than 65 years old; first-degree relatives include parents, siblings, and offspring
  • Cigarette smoking: Current cigarette smoker or quit within the previous six months, or exposure to secondhand smoke
  • Sedentary lifestyle: Does not participate in at least 30 minutes of moderate-intensity  physical activity on at least three days/week for at least three months (remember this by thinking of the 3’s—30 minutes, for 3 days, for 3 months)
  • Obesity: Client has a BMI ≥30 kg/m2
  • Hypertension: Blood pressure ≥140/90 mmHg  or currently on antihypertensive medications; both numbers do not have to be above the defining criteria for a + 1 in this category; if either the systolic reading is ≥ 140 mmHg or the diastolic number is ≥ 90 mmHg, the client would get a +1 in this category
  • Cholesterol: Total cholesterol should only be used if it is the only value given; if using total, ≥200 mg/dL is considered a risk (+1)
  • If you are given LDL and HDL cholesterol, use these values only:
    • LDL (bad cholesterol) ≥130 mg/dL is a risk (+1)
    • HDL (good cholesterol, you want lots) <40 mg/dL is a risk (+1)
    • HDL (good cholesterol) ≥60 mg/dL is good, allowing an individual to take a risk away (-1)
    • PreDiabetes: Fasting glucose ≥100 mg/dL is a risk (+1)

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


  • Low risk =  Asymptomatic and < 2 risk factors
  • Moderate risk =  Asymptomatic ≥ 2 risk factors
  • High risk = Symptomatic (see signs and symptoms below) or if the client has a known cardiac, pulmonary, renal, or metabolic disease

Signs and Symptoms:

  • Pain (tightness) or discomfort (or other angina equivalent) 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) or paroxysmal nocturnal dyspnea (onset is usually two to five hours after the beginning of sleep)
  • 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
  • Dizziness or syncope, most commonly caused by reduced perfusion to the brain
Consider the following Case Studies to see if you are on the right track. The correct answers are listed below.

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 past 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 training, regularly running for 7+ hours a week for the past year


Client 1 : Moderate risk (+3 risks): +1 for blood pressure, +1 for total cholesterol, and  +1 for sedentary lifestyle

Client 2 : Low risk (+2 risks, -1 risk): +1 for age, +1 for sedentary lifestyle, and -1 for HDL cholesterol

Client 3 : High risk: Known heart murmur