PAR-Q+ Positive, Stage 2 Blood Pressure, and Twenty Minutes to Class
A 52-year-old man comes to your facility's new-member orientation and asks to join your high-intensity interval class, which starts in 20 minutes. On the PAR-Q+ he answers yes to the chest-pain question and writes that he 'sometimes gets tightness in the chest when shoveling heavy snow,' but says it passes with rest and he has not seen a doctor in four years. You take a seated blood pressure after five minutes of rest: 148/92 mmHg, repeated once, same reading. Resting heart rate is 78 bpm. His father had a heart attack at 58. He is not on any medications, does not smoke, and walks 30 minutes three times a week. He is eager, already changed, and says he 'doesn't want to make a big deal of it.' The class has 18 people and one instructor-you.
1. Interpret the screening information and state whether he can join today's class, with your reasoning.
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He cannot join today's class.
- Chest pain on the PAR-Q+. A 'yes' to the chest-pain question is a positive screen requiring medical clearance before moderate-to-vigorous exercise. The instructor's role is to screen and refer, not to diagnose, risk-stratify, or clear. The reported pattern - exertional tightness relieved by rest - is a symptom that needs a clinician's evaluation regardless of what it eventually turns out to be.
- Blood pressure. 148/92 on a repeated seated reading is stage 2 hypertension under ACC/AHA thresholds (≥140/90), and he is unmedicated and unmonitored. A single office-style reading is not a diagnosis, but two consistent readings plus a symptom is not something to wave through.
- Risk factors. Age 52, a first-degree relative with MI at 58, and a sedentary-to-light activity pattern add up. The combination of symptoms plus risk factors is what matters, not any single number.
The temptation is to reason 'he walks three times a week, it's probably nothing.' That reasoning is how incidents happen, and it is outside your scope. The answer is a warm, firm 'not today, and here is exactly what happens next.'
2. What exactly do you document and communicate, and what do you offer him instead?
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Document: date and time; his PAR-Q+ answers verbatim, especially the chest-pain response and his own description; both BP readings with the arm, position, and rest interval; resting heart rate; the fact that you referred him and to whom; and what you told him. Note that he was not cleared to participate today.
Communicate: give him the PAR-Q+ follow-up page to take to a clinician, and be specific that the clearance needs to address exertional chest pain, not just 'can I exercise.' Do not accept a signed facility waiver as a substitute for medical clearance; a waiver is not a clinical assessment. Tell the facility manager the same day so the decision is not resting on you alone, and so the front desk does not let him into another class.
Offer: if facility policy and your insurance allow, a supervised low-to-moderate option while he waits - a walking group or low-impact class at RPE 11–13 on the talk test, with explicit stop rules for chest tightness, dizziness, unusual shortness of breath, or palpitations. No interval work, no maximal efforts. Set a follow-up date and check in with him. Telling him 'no' without an alternative loses him; telling him 'yes' without clearance risks him.
3. What would change if he returned with a signed physician clearance and a resting BP of 128/78?
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He can start - but not at the top of the class.
Read the clearance letter for specifics, not just the signature. Does it state restrictions (a heart-rate ceiling, a stress-test result, a limit on intensity, a symptom-stop rule)? A generic 'may exercise' is less useful than a letter that says what he may do.
Programme the entry: begin with one or two interval bouts at moderate intensity inside a low-impact format, use RPE and the talk test rather than heart rate alone if he is not on rate-limiting medication, and progress work-to-rest over three to four weeks. A single normal reading does not erase the history or the symptom - the plan still needs a symptom-stop rule, an emergency action plan, and documented re-screening at intervals. Re-check blood pressure periodically and keep the physician's letter on file.
What should not change: the referral culture. The fact that he came back cleared is the system working, not evidence that the original screen was overcautious.