Marcus, 58: Stage 2 Hypertension, a Sedentary Decade, and a HIIT Class on Monday
Marcus, 58, is starting his first month of training. He is sedentary, takes no medications, and has no diagnosed cardiovascular, metabolic, or renal disease. Screening reveals: BP 148/92 mmHg (confirmed on two occasions), BMI 31, father had an MI at 59, and he has not exercised in 12 years. He has no chest pain, dyspnea at rest, dizziness, or edema. His goal is to 'get shredded' with a 20-minute HIIT class three days a week starting next week, because a coworker lost weight doing it. He asks you to write the plan for Monday and says he does not want to 'bother a doctor about it.'
1. Does Marcus need medical clearance before Monday? Walk through the decision and say exactly what you will document.
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Work the algorithm, not the risk-factor count alone.
- Signs or symptoms of disease? None. He denies chest pain, dyspnea, dizziness, and edema. If any of those were present, the answer changes immediately.
- Known cardiovascular, metabolic, or renal disease? None reported.
- Therefore medical clearance is not required before moderate or vigorous exercise, even though he has at least four risk factors (age over 45, family history of MI before 55 in a male first-degree relative, sedentary, obesity, BP over 140/90). Risk factors drive monitoring and program design, not the clearance decision. This is the part most candidates get backwards.
- The BP still needs a flag. 148/92 is stage 2 hypertension by ACC/AHA thresholds. That is not a contraindication to moderate exercise, but it is a reason to recommend physician follow-up for BP management. Hold exercise and refer the same day if you ever measure 180/110 or higher.
Document: the screening answers, the absence of symptoms, the risk-factor list, the decision that clearance is not required, the BP readings with dates, and the recommendation that his physician review his BP. Never tell him he is 'cleared' - you are not the clearing authority.
2. He wants the 20-minute HIIT class on Monday. What do you actually run, and what are you watching for?
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Do not run the class as written. The risk here is not cardiac - it is a 12-year-sedentary man with obesity and uncontrolled BP doing near-maximal intervals in week one and either getting hurt or quitting.
Weeks 1-4 (aerobic base): 3-4 days/week of 20-30 minutes at 40-59% heart-rate reserve, RPE 11-13, using the talk test - he should be able to speak in full sentences. Build toward 150 minutes/week. Resistance: 2 days/week, machines or bodyweight, 1-2 sets of 10-15, with explicit coaching to exhale on exertion. Valsalva is the thing to kill early with his BP.
Weeks 5+ (intervals): only after he can complete 30 minutes comfortably. Start at 1 minute of work (RPE 14-15, not maximal) to 2-3 minutes of easy recovery, 4-6 rounds. Progress duration before intensity.
Watch for: chest discomfort, disproportionate breathlessness, lightheadedness, pallor or clamminess, an unusual drop in work capacity between rounds, and slow heart-rate recovery. Stop the session for any of those and document it. Check BP before and after if a cuff is available.
3. Six weeks in, he reports that he 'felt weird' during a session - briefly lightheaded, no chest pain, resolved in a minute when he sat down. He wants to continue. What do you do?
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A symptom is a change in category. Once a symptom appears, he is no longer the asymptomatic client the screening decision was based on, so the clearance logic no longer applies.
- Stop and assess now: what was he doing, how hard, how long, what had he eaten and drunk, was he holding his breath, was it at the end of a set or on standing? Get a seated and standing BP if you can.
- Refer for medical evaluation before his next vigorous session. Lightheadedness on exertion in a 58-year-old with stage 2 hypertension and a family history is not something to train through.
- Moderate exercise in the meantime is a judgement call you make with him and his physician's input - but do not simply resume the interval work.
- Document the event, the action, and the referral. If he declines, document that too, in his words.
- Re-examine your own program: had you progressed him faster than the plan, was he breath-holding on presses, was the room hot, was he fasted?