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Textbook/Cardiovascular medicine/Exercise testing and stress imaging
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Exercise testing and stress imaging

Select an anatomical or functional test for suspected coronary disease and conduct stress testing safely, recognising when exercise ECG is the wrong diagnostic tool.

18 min full readUK scopeSources checked 27 Aug 2026Clinical review pending
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Time-critical presentation

Do not stress-test ongoing ACS, uncontrolled arrhythmia, decompensated heart failure, symptomatic severe aortic stenosis or another unstable condition; stabilise and use the acute pathway.

Open the sections you need. The overview is shown first.
01Purpose and principlesWhat the assessment is for and the core concepts behind it.

Anatomical tests ask whether coronary plaque or stenosis is present; functional tests ask whether stress produces ischaemia. Choose the question that remains after clinical assessment and any prior imaging.

Stress echocardiography detects inducible wall-motion change without ionising radiation; perfusion CMR characterises tissue as well as perfusion; SPECT and PET assess perfusion, with PET permitting quantitative flow in experienced centres.

Baseline ECG abnormalities, inability to exercise, body habitus, arrhythmia, renal function, implanted devices, radiation exposure and local expertise shape modality choice.

Key points

  • NICE does not recommend exercise ECG to diagnose stable angina in people without known coronary artery disease.
  • Under NICE CG95, CT coronary angiography is first-line when clinical assessment suggests typical or atypical angina.
  • Functional imaging tests inducible ischaemia and includes stress echocardiography, stress perfusion CMR, SPECT and PET where available.
  • Exercise is preferred over pharmacological stress when the modality permits and the patient can reach an adequate workload safely.
  • A test is non-diagnostic if workload, heart-rate response, image quality or tracer response is inadequate.
  • Stop for limiting symptoms, significant hypotension or hypertension, serious arrhythmia or diagnostic high-risk ischaemic change.
  • Interpret symptoms, workload, haemodynamics, ECG and imaging together; a binary 'positive/negative' label discards risk information.
02Indications, selection and cautionsWhen it is useful, when urgency changes and important limitations.
High-risk stress responseRed flag

Ischaemia at low workload, extensive inducible abnormality, exertional hypotension or serious ventricular arrhythmia requires prompt specialist review.

Inducible wall-motion abnormality

New or worsening regional dysfunction during stress supports flow-limiting coronary disease in the corresponding territory.

Reversible perfusion defect

Reduced stress uptake or perfusion that normalises at rest indicates inducible ischaemia; fixed defects may reflect scar or artefact.

Inadequate stress

Failure to achieve sufficient workload, chronotropic response or vasodilator effect makes a normal-appearing result potentially non-diagnostic.

Non-coronary exercise limitation

Symptoms with poor fitness, lung disease, anaemia, chronotropic incompetence or abnormal blood-pressure response may explain limitation without proving epicardial stenosis.

03Method and interpretationA systematic approach to the test and its findings.
Investigation order

Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.

  1. 01
    Exercise treadmill ECGFirst step
    Why
    Assess exercise capacity, symptoms, blood-pressure response and exercise arrhythmia in selected patients, particularly with known CAD.
    Interpretation and limitations
    Do not use it as the diagnostic test for stable angina in people without known CAD under NICE CG95; baseline ST abnormality also reduces interpretability.
  2. 02
    Stress echocardiography
    Why
    Detect inducible regional wall-motion abnormality with exercise or pharmacological stress.
    Interpretation and limitations
    Image quality and achieving adequate stress are essential; contrast may improve endocardial definition.
  3. 03
    Stress perfusion CMR
    Why
    Assess ischaemia, ventricular function and scar without ionising radiation.
    Interpretation and limitations
    Reversible subendocardial perfusion abnormality supports ischaemia; review device and gadolinium safety.
  4. 04
    SPECT myocardial perfusion imaging
    Why
    Map relative perfusion at stress and rest.
    Interpretation and limitations
    Differentiate reversible from fixed defects while checking attenuation, motion and balanced-ischaemia limitations.
  5. 05
    PET perfusion imaging
    Why
    Assess perfusion with potential absolute myocardial blood-flow and flow-reserve quantification.
    Interpretation and limitations
    Reduced global flow reserve may reveal diffuse epicardial disease or microvascular dysfunction even without a focal defect.
04Clinical next stepsHow the result changes management or prompts escalation.
01Preferred routeSuspected stable angina without known CADFirst stepPreferredTypical or atypical stable symptoms and no acute features
  1. 1AlternativeAssess symptoms, cardiovascular risk, resting ECG and alternative diagnoses.
  2. 2Offer 64-slice-or-above CT coronary angiography under NICE CG95 rather than exercise ECG for diagnosis.
  3. 3If CTCA is non-diagnostic or shows disease of uncertain functional significance, offer non-invasive functional imaging.
  4. 4Use invasive angiography when non-invasive results and symptoms indicate high risk or remain inconclusive and management will change.
02AlternativeSelecting functional imagingAlternativeIschaemia assessment is needed
  1. 1Choose exercise stress if the patient can exercise safely and the modality supports it; otherwise select a validated pharmacological protocol.
  2. 2Match echo, CMR, SPECT or PET to acoustic windows, rhythm, device, renal function, radiation considerations and expertise.
  3. 3Record whether target stress was achieved and any limiting factor.
  4. 4Integrate ischaemic burden with anatomy, ventricular function, symptoms and treatment preferences.
03EscalationAbnormal or unsafe stress responseEscalationLow-workload ischaemia, hypotension, serious arrhythmia or limiting chest pain
  1. 1Terminate stress, monitor, obtain a 12-lead ECG and treat acute symptoms.
  2. 2EscalationEscalate persistent symptoms or ECG change through the ACS pathway.
  3. 3Arrange urgent cardiology review for high-risk imaging or haemodynamic findings.
  4. 4Do not repeat stress testing simply to confirm a clearly high-risk result.
05Risks, monitoring and follow-upComplications, safety checks and further assessment.
  • Before testing record symptoms, medicines, resting ECG, blood pressure and contraindications.
  • During stress monitor ECG, symptoms, blood pressure and rhythm with immediate resuscitation capability.
  • Document workload or pharmacological endpoint and why testing stopped.
  • Observe until symptoms, ECG and haemodynamics return appropriately toward baseline.
  • Track timely action on high-risk or non-diagnostic results.
06Special situationsVariants, exceptions and circumstances that change the usual approach.

A negative inadequate test is not reassuring

If sufficient stress was not achieved, the post-test probability may remain materially unchanged.

Beta-blockers can blunt exercise

Medication withholding depends on the clinical question and test protocol; do not stop drugs without an authorised plan.

Balanced ischaemia

Relative SPECT perfusion can underestimate extensive multivessel disease when all territories are similarly underperfused.

PET can quantify flow

Reduced myocardial flow reserve may support diffuse or microvascular disease beyond focal stenosis imaging.

Known versus suspected CAD matters

Exercise ECG retains value for exercise capacity and arrhythmia assessment even though NICE advises against it for diagnosing stable angina without known CAD.

07Common pitfallsFrequent interpretation and management errors.
  1. 01

    Ordering an exercise ECG as the first diagnostic test for suspected stable angina without known CAD.

  2. 02

    Calling a submaximal study negative.

  3. 03

    Stress-testing a patient with active unstable symptoms.

  4. 04

    Ignoring baseline ECG abnormality that prevents ST-segment interpretation.

  5. 05

    Treating a perfusion defect as anatomy without correlating with CT or angiography.

Practice

Two practice questions

Question 1 of 20 correct
CardiologyOriginal SBA

First test for suspected angina

A stable outpatient with no known CAD has typical angina and a normal resting ECG. Under NICE CG95, which test should be offered first?

Sources and review status4 sources · checked 27 Aug 2026 · clinical review pending
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

Authoring stateComplete draftClinical stateAwaiting reviewJurisdictionUnited Kingdom