Intended for healthcare professionals

Practice Uncertainties

Assessment of chest pain in a low risk patient: is the exercise tolerance test obsolete?

BMJ 2015; 350 doi: (Published 06 May 2015) Cite this as: BMJ 2015;350:h1905
  1. Kevin Barraclough, general practitioner1,
  2. Chris P Gale, associate professor, honorary consultant cardiologist2,
  3. Roger Hall, professor of clinical cardiology3
  1. 1Hoyland House, Painswick GL6 6TY, UK
  2. 2Centre for Epidemiology and Biostatistics, University of Leeds, Leeds LS2 9JT, UK
  3. 3Norwich Medical School, , University of East Anglia, Norwich NR4 7TJ, UK
  1. Correspondence to: K Barraclough k.barraclough{at}

The bottom line

  • The coronary artery calcium score has high sensitivity for detecting coronary stenosis—so a negative result makes significant coronary stenosis unlikely—but low specificity, and 60% of those without coronary artery disease will also have a positive result

  • Thus many low risk patients may be diagnosed with coronary artery disease using the calcium score, although they may have clinically insignificant or “bystander” disease. These patients may benefit little from investigation and treatment and may be harmed

  • The exercise tolerance test is a quick, functional investigation that measures maximum exercise tolerance. In low risk patients who are likely to achieve a high workload the test can identify patients with high relative survival without the need for further imaging

A 55 year old man presents with chest pain that he has had for a few months. He is a keen cyclist and a non-smoker with normal blood pressure. He has a serum total cholesterol concentration of 6.1 mmol/L (with an high density lipoprotein cholesterol concentration of 1.5 mmol/L). The chest pain is anterior, poorly localised, mild, and intermittent, though sometimes associated with exercise. It generally resolves after a few minutes whether or not the patient continues to exercise. Examination and his resting 12 lead electrocardiograph are normal.

Assessment guidelines

Three international guidelines for the assessment of new onset of chest pain provide different advice about how an individual at low or medium likelihood of coronary artery disease should be investigated (table 1). The American Heart Association1 and European Society of Cardiology2 advocate the exercise tolerance test or functional cardiac imaging. However, in 2010, the UK National Institute for Health and Care Excellence (NICE) took a new approach and recommended that, for patients who had a low likelihood of coronary artery disease, coronary artery calcium scoring should be the first line investigation, replacing the …

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