Patient Assessment
18%of exam
ACS SpectrumHF ClassificationBP & PAD StagingMetabolic & Diabetes CriteriaPulmonary StagingPreparticipation ClearanceDKA vs HHSMONA Mnemonic
Exercise Testing
18%of exam
Test ProtocolsECG Basics & BlocksIschemia & Infarction ECGInterpreting ResultsContraindicationsTermination TriageDigoxin vs Ischemia
Exercise Prescription
22%of exam
FITT-VP & IntensityMET & Metabolic MathIntensity SelectionFITT-VP Mnemonic
Exercise Training and Leadership
24%of exam
Education and Behavior Change
13%of exam
Legal and Professional Responsibilities
5%of exam
Quick Facts
- Exam
- ACSM-CEP
- Credential
- Clinical Exercise Physiologist
- Items
- 115 (100 scored)
- Time
- 210 minutes
- Pass
- 550/800 scaled
- Domains
- 6 weighted domains
- Fee
- $350 member / $460
- Provider
- Pearson VUE
- Blueprint
- Jul 10, 2025
MONA (ACS Recognition)
Morphine, Oxygen, Nitrates, Aspirin
M: pain reliefO: only if hypoxicN: raises ischemic thresholdA: antiplatelet therapy
DKA vs HHS
DKA
- Glucose usually >250
- Ketones positive, pH low
- Type 1 diabetes, rapid
- Kussmaul breathing, fruity breath
HHS
- Glucose usually >600
- Ketones minimal, pH normal
- Type 2, older, slower
- Severe dehydration, confusion
Acidotic vs hyperosmolar crisis
Preparticipation Clearance Decision
- Inactive, no symptoms→No clearance needed(For light-moderate exercise)
- Inactive, symptoms or disease→Clearance recommended(Before starting program)
- Active, known disease only→Continue current program(Clearance before vigorous)
- Active, new symptoms appear→Discontinue, seek clearance(Overrides activity history)
ACS Spectrum
- Stable angina
- Fixed stenosis, rest relief
- Unstable angina
- Rest pain, negative troponin
- NSTEMI
- Partial occlusion, positive troponin
- STEMI
- Complete occlusion, ST elevation
- Silent ischemia
- No pain despite ECG change
- Anginal equivalent
- Dyspnea, fatigue, jaw pain
Heart Failure Classification
- HFrEF
- EF 40% or less
- HFmrEF
- EF 41 to 49%
- HFpEF
- EF 50% or more
- NYHA I
- No symptom limitation
- NYHA II
- Symptoms with ordinary activity
- NYHA III
- Symptoms with less activity
- NYHA IV
- Symptoms present at rest
BP and PAD Staging
- Normal BP
- Under 120/80 mmHg
- Elevated BP
- 120-129, under 80
- Stage 1 hypertension
- 130-139 or 80-89
- Stage 2 hypertension
- 140+ or 90+
- ABI normal
- 1.00 to 1.40
- ABI mild-moderate PAD
- 0.41 to 0.90
- ABI severe PAD
- 0.40 or below
Metabolic and Diabetes Criteria
- Diabetes A1C
- 6.5% or higher
- Diabetes fasting glucose
- 126 mg/dL or higher
- Diabetes OGTT
- 200 mg/dL, 2-hour
- MetSyn diagnosis
- 3 of 5 criteria
- MetSyn triglycerides
- 150 mg/dL or higher
- MetSyn blood pressure
- 130/85 mmHg or higher
- MetSyn fasting glucose
- 100 mg/dL or higher
Pulmonary Staging
- COPD diagnosis
- FEV1/FVC under 0.70
- GOLD 1
- FEV1 80% or more
- GOLD 2
- FEV1 50 to 79%
- GOLD 3
- FEV1 30 to 49%
- GOLD 4
- FEV1 under 30%
- GOLD Group E
- 2+ exacerbations, any symptoms
- Exercise SpO2 floor
- 88 to 90%
Absolute vs Relative Contraindications
Absolute
- Recent MI, 2-3 days
- Unstable angina
- Uncontrolled arrhythmia
- Acute aortic dissection
Relative
- Left main stenosis
- Severe resting hypertension
- High-grade AV block
- Hypertrophic cardiomyopathy
Defer testing vs weigh risk
Test Termination Triage
- Patient requests stop→Terminate now(Absolute, no exceptions)
- Sustained VT appears→Terminate now(Absolute indication)
- ST elevation 1mm+→Terminate now(No prior Q waves)
- SBP drop + ischemia signs→Terminate now(Absolute indication)
- SBP >250 or DBP >115→Terminate now(Hypertensive response)
- ST depression >2mm→Usually stop(Relative, use judgment)
- Multifocal PVCs, couplets→Usually stop(Relative indication)
- Increasing chest pain→Usually stop(Relative indication)
Exercise Test Protocols
- Bruce protocol
- 3-min stages, general use
- Modified Bruce
- Adds low-intensity start stages
- Naughton protocol
- 1-MET steps, cardiac patients
- Cycle ramp
- Continuous rise, best for CPET
- Ideal test length
- 8 to 12 minutes
- Treadmill VO2peak
- 5-10% higher than cycling
- Cycle ergometry ECG
- More stable, less artifact
Absolute vs Relative Termination
Absolute
- Patient requests stop
- Sustained VT
- ST elevation 1mm+
- Poor-perfusion signs
Relative
- Marked ST depression
- Multifocal PVCs
- Increasing chest pain
- Hypertensive response
Stop always vs use judgment
ECG Basics and AV Blocks
- Normal PR interval
- 0.12 to 0.20 sec
- Normal QRS duration
- Under 0.12 seconds
- ECG paper speed
- 25 mm per second
- Small ECG box
- 0.04 seconds
- Mobitz I
- PR lengthens, then drops
- Mobitz II
- Constant PR, sudden drop
- Third-degree block
- P and QRS independent
Digoxin Effect vs True Ischemia
Digoxin effect
- Downsloping, scooped shape
- Present at rest too
- Therapeutic-dose finding
- Shortens QT interval
True ischemia
- Horizontal/downsloping, 1mm+
- New with exercise
- Resolves during recovery
- Signals reduced blood flow
Medication effect vs new ischemia
Ischemia and Infarction ECG
- Ischemia sign
- ST-segment depression
- Injury sign
- ST-segment elevation
- Infarction sign
- Pathologic Q wave
- Ischemic ST depression
- 1mm+ horizontal or downsloping
- Pathologic Q wave
- 0.04 sec, 25% of R
- Anterior MI leads
- V3 and V4
- Inferior MI leads
- II, III, aVF
- Lateral MI leads
- I, aVL, V5-V6
Interpreting Test Results
- Rate-pressure product
- HR times systolic BP
- Duke Treadmill Score
- Time, ST deviation, angina index
- DTS low risk
- +5 or higher
- DTS high risk
- -11 or lower
- Maximal-effort RER
- 1.10 or higher at peak
- Ventilatory threshold
- Submaximal, effort-independent marker
- Mason-Likar placement
- Limb leads moved to torso
FITT-VP
Frequency, Intensity, Time, Type, Volume, Progression
F: days/weekI: %HRR or RPET: session minutesT: activity typeV: weekly MET totalP: advance slowly
Exercise Intensity Selection
- GXT HRmax measured→Karvonen %HRR(Most precise HR method)
- Beta-blocker or pacemaker→RPE Borg 6-20(HR response unreliable)
- Atrial fibrillation present→RPE or talk test(HR unpredictable)
- Gas-exchange data available→Ventilatory threshold(Highest precision option)
- No GXT performed→Skip age-predicted HRmax(Wide individual error)
- Deconditioned, tolerating program→Increase time first(Then frequency, then intensity)
FITT-VP and Intensity
- Aerobic frequency
- 3 to 5 days/week
- Moderate intensity
- 40-59% heart rate reserve
- Vigorous intensity
- 60-89% heart rate reserve
- Karvonen formula
- HRR-based target heart rate
- Weekly volume goal
- 500 to 1,000 MET-min
- Resistance starting load
- 40 to 60% of 1RM
- Progression order
- Time, then frequency, then intensity
MET and Metabolic Math
- 1 MET
- 3.5 mL/kg/min oxygen
- RER near 0.70
- Mostly fat oxidation
- RER near 1.00
- Mostly carb oxidation
- Kcal per liter O2
- About 5 kcal
- mph to m/min
- Multiply by 26.8
- Watts to kgm/min
- Multiply by 6 (ACSM)
Rate-Limiting Drugs (BAND)
Beta-blockers, Amiodarone, Non-DHP CCBs, Digoxin blunt HR
B: beta-blockersA: amiodaroneN: non-DHP CCBsD: digoxin, rate control
Beta-Blocker vs DHP-CCB
Beta-blockers
- Blunt HR throughout exercise
- Use RPE, not %HRmax
- Bronchospasm risk (nonselective)
- Mask hypoglycemia warning signs
DHP CCBs
- Minimal direct HR effect
- Reflex tachycardia possible
- Peripheral edema common
- No hypoglycemia masking
HR-blunting vs vasodilating
Rate-Limiting and Vasoactive Drugs
- Beta-blockers
- Blunt HR, use RPE
- Non-DHP CCBs
- Blunt HR and AV node
- DHP CCBs
- Vasodilate, reflex tachycardia
- Nitrates
- Raise ischemic threshold
- Nitrate plus PDE-5 inhibitor
- Absolute contraindication, severe hypotension
- ICD training ceiling
- 10-20 bpm below shock zone
Other Drug Effects
- Digoxin ECG effect
- Scooped ST depression
- Diuretics
- Post-exercise hypokalemia arrhythmia risk
- Amiodarone toxicity
- Pulmonary and thyroid effects
- Statins
- Myalgia, rare rhabdomyolysis
- Anticoagulants/antiplatelets
- Bleeding risk, avoid contact
- SGLT2 inhibitors
- Euglycemic DKA risk
- Beta-2 agonists
- Expected mild tachycardia
Behavior Change Tools
- Transtheoretical Model
- Stages of change
- Health Belief Model
- Perceived risk and benefit
- Self-Determination Theory
- Autonomy, competence, relatedness
- Motivational interviewing
- Elicits patient's own motivation
- PAR-Q+
- Self-guided readiness screen
Chain of Survival
Recognize, Call, CPR, Shock, Advanced care, Recovery
1: recognize, call EMS2: early high-quality CPR3: early defibrillation4: advanced EMS care5: post-arrest care6: recovery
CEP vs EP-C Scope
ACSM-CEP
- Clinical hours required
- Unstable, high-risk patients
- ECG-monitored testing
- Medication-adjusted prescription
EP-C
- No clinical hours
- Healthy or stable patients
- Non-medical settings
- General fitness prescription
Clinical scope vs non-clinical
Negligence and Informed Consent
- Negligence elements
- Duty, breach, causation, damages
- Consent timing
- Before testing or training
- Consent must cover
- Risks, benefits, alternatives, stop right
- HIPAA standard
- Minimum necessary PHI use
- Standard of care
- Reasonably prudent CEP action
15-15 Rule
15 grams carbs, wait 15 minutes, recheck
Glucose below 70 = treatGive 15g fast carbWait 15 minutesRecheck, repeat if low
Emergency Response Basics
- CPR compression rate
- 100 to 120 per minute
- CPR compression depth
- 2 to 2.4 inches
- CPR ratio
- 30:2, single rescuer
- Hypoglycemia rule
- 15g carb, recheck 15 min
- Heat stroke threshold
- Over 104F plus CNS signs
- BLS requirement
- Required for all CEP staff
- ACLS requirement
- 1+ staff in clinical programs
Common Traps
Syncope timing
Vasovagal after exercise ≠ Cardiac during exercise
Digoxin Effect vs True Ischemia
Scooped, present at rest ≠ New change during exercise
Risk Factors vs Clearance Algorithm
Risk count sets test supervision ≠ 3-factor algorithm sets clearance
VO2max vs VO2peak
Max implies a true plateau ≠ Peak is highest value seen
Mobitz I vs Mobitz II
PR lengthens before it drops ≠ PR stays constant, drops suddenly
DHP vs Non-DHP CCB
DHP vasodilates, reflex tachycardia ≠ Non-DHP blunts HR like BB
CABG vs PCI Precautions
CABG: 6-8 wks, no lifting ≠ PCI: 24-48 hrs, site only
Last Minute
- 1.Weights 18-18-22-24-13-5
- 2.115 items, 550 pass, 210min
- 3.Absolute stop: VT, ST-elevation, request
- 4.Relative stop: ST-depression, multifocal PVCs
- 5.Beta-blockers blunt HR, use RPE
- 6.Digoxin scoops ST, not ischemia
- 7.SGLT2i: euglycemic DKA risk
- 8.Know Duke Treadmill Score formula
- 9.Mason-Likar: limb leads to torso
- 10.CPR 30:2, depth 2-2.4in
- 11.Hypoglycemia: 15g carb, recheck 15min
- 12.Negligence: duty, breach, causation, damages
- 13.CEP clinical hours; EP-C none
- 14.RER 1.10 = max effort
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