Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
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Escalate
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.
Synopsis
Select an anatomical or functional test for suspected coronary disease and conduct stress testing safely, recognising when exercise ECG is the wrong diagnostic tool.
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.
Key red flags
High-risk stress response
Ischaemia at low workload, extensive inducible abnormality, exertional hypotension or serious ventricular arrhythmia requires prompt specialist review.
Investigation priorities
01
Exercise treadmill ECGFirst step
Assess exercise capacity, symptoms, blood-pressure response and exercise arrhythmia in selected patients, particularly with known CAD.
Management branches
Preferred routeSuspected stable angina without known CAD
Typical or atypical stable symptoms and no acute features
Assess symptoms, cardiovascular risk, resting ECG and alternative diagnoses.
Offer 64-slice-or-above CT coronary angiography under NICE CG95 rather than exercise ECG for diagnosis.
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.