Exercise Tolerance Tests

Key points

• Per NICE CG95 (updated 2016), the exercise ECG (ETT) is NOT recommended to diagnose or exclude stable angina in people without known CAD — CT coronary angiography (CTCA) is first-line, with non-invasive functional imaging second-line. ETT still has a role in assessing exercise capacity and some risk stratification (post-MI, hypertrophic cardiomyopathy).
• Sensitivity ~80% and specificity ~70% for ischaemic heart disease. Maximum predicted heart rate = 220 - age; aim for at least 85% of maximum predicted.
• Contraindications: MI less than 7 days ago, unstable angina, uncontrolled hypertension (SBP over 180) or hypotension (SBP under 90), severe aortic stenosis, LBBB (uninterpretable ECG).
• Stop for: exhaustion or patient request, severe/limiting chest pain, ST depression over 3 mm, or ST elevation over 2 mm.
• Stop for: SBP over 230 mmHg, SBP falling more than 20 mmHg, reaching maximum predicted heart rate, heart rate falling more than 20% of starting rate, or a new arrhythmia.

Decision points in this pathway

• Contraindication present? (myocardial infarction less than 7 days ago · unstable angina · uncontrolled hypertension SBP > 180 mmHg or hypotension SBP < 90 mmHg · aortic stenosis · left bundle branch block)

The full step-by-step algorithm, including what to do at each branch, opens in the app for approved members.