The diagnosis of coronary heart disease (CHD) as the cause of chest pain requires the use of a careful clinical history as well as additional investigation. Coronary angiography is considered the "gold standard" of diagnostic tests, but its limitations (invasive, costly, and does not yield physiologic information) make it appropriate as an initial study in only a minority of patients (table 1) [1,2]. (See "Diagnostic approach to chest pain in adults", section on 'Evaluation'.)
The evaluation of patients presenting with chest pain suspected to be due to CHD often includes some form of non-invasive stress testing. Several tests that vary in both accuracy and cost are available. The optimal testing strategy, including the possible use of more than one test, differs according to the patient population .
The major questions to be addressed before selecting one or more of the available diagnostic tests are:
- What is the patient's pretest risk of CHD?
- How accurate are the alternative tests?
- What are the costs and effects on health outcomes of each test?
- Do special considerations make one test more suitable in a specific patient?
The use of stress testing as part of a cost-effective approach to the diagnosis of CHD will be reviewed here; there will be an emphasis on the exercise ECG test. The overall approach to the patient who presents with chest pain and the advantages and limitations of the different stress testing modalities are discussed separately. (See "Diagnostic approach to chest pain in adults" and "Selecting the optimal cardiac stress test".)