Repositioning of exercise treadmill testing in contemporary chest pain management

Chest pain evaluation has become increasingly imaging-led with widespread use of coronary CT angiography (CTCA) and stress imaging (e.g., CMR, stress echocardiography). In this context, the clinical role of exercise treadmill testing (ETT) is debated because its accuracy for obstructive coronary artery disease (CAD) is generally lower than that of contemporary imaging.

This narrative review reassesses the value of ETT in current chest pain care by summarizing diagnostic performance, exercise-derived prognostic/functional information, cost and resource implications, and its positioning in major society guidelines, to clarify where ETT remains clinically useful.

PubMed, Embase, and the Cochrane Library were searched for English-language studies published from 2010 onward. Priority was given to major clinical guidelines, diagnostic meta-analyses, prognostic cohort studies, and cost-effectiveness evaluations relevant to stable or low-to-intermediate risk chest pain assessment.

Contemporary evidence shows that ETT has modest sensitivity for obstructive CAD but retains reasonable specificity when used in appropriately selected patients with an interpretable baseline ECG and adequate exercise capacity. Beyond diagnostic classification, ETT yields physiologic and functional markers-exercise capacity, chronotropic response, heart rate recovery, blood pressure response, symptom reproduction, and arrhythmia provocation-that are strongly associated with future cardiovascular outcomes and are not fully captured by anatomic testing alone. As an inexpensive, widely available test that avoids radiation and iodinated contrast, ETT remains a pragmatic option for low-risk patients and for systems with limited access to advanced imaging. Current ESC and AHA/ACC guidance continues to reserve a role for exercise ECG within risk-adapted pathways, particularly for functional assessment and selected diagnostic scenarios.

ETT should be viewed as complementary to advanced imaging rather than competitive. When embedded in risk-stratified pathways and applied to the right population, it provides clinically meaningful functional and prognostic information at low cost. Its utility is greatest in low-risk stable chest pain, for exercise physiology assessment, and in resource-constrained settings.