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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.

Exercise testing and stress imaging

Cardiology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

RapidFull
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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.
  • 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.

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

  1. Assess symptoms, cardiovascular risk, resting ECG and alternative diagnoses.
  2. Offer 64-slice-or-above CT coronary angiography under NICE CG95 rather than exercise ECG for diagnosis.
  3. If CTCA is non-diagnostic or shows disease of uncertain functional significance, offer non-invasive functional imaging.
  4. Use invasive angiography when non-invasive results and symptoms indicate high risk or remain inconclusive and management will change.
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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. Apply principles in context and verify current guidance when a decision affects care. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • NICE CG95: Recent-onset chest pain
  • ESC 2024 Guidelines for chronic coronary syndromes
  • ESC/EACVI non-invasive imaging in coronary syndromes
  • NICE NG208: Heart valve disease presenting in adults

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom