Exercise electrocardiogram (ECG) for screening for coronary heart disease
Best Practice Guidance
Exercise electrocardiogram (ECG) is a type of cardiac stress test that should no longer be used to screen for coronary heart disease (CHD).
This guidance applies to adults aged 19 years and over.
Exercise ECG has no role in the screening of asymptomatic and low risk patients for coronary heart disease because it has a very low pre-test probability of identifying pathology. Risk calculators, such as Systematic Coronary Risk Evaluation (SCORE), are instead recommended to identify patients who are at greater risk of CHD.
Under the guidance of cardiologists, the test has a limited role for diagnosis in selected patients with symptoms suggestive of CHD, and/or where CHD has been diagnosed to confirm functional capacity or severity.
Rationale for recommendation
In randomised control trials, screening with exercise ECG in asymptomatic patients found no improvement in health outcomes, even when focussing on higher risk populations such as those with diabetes. There is no research examining whether the addition of exercise ECG to traditional CHD risk factors results in accurate reclassification, however cohort studies looking at the role of resting ECG abnormalities found inconsistent impact on clinical decisions.
Reliability of exercise ECG testing varies based on many features including age, gender and known history of CHD, which significantly limits its utility as a screening tool. ECG sensitivity has been cited as 45-50% and specificity of 85-90%. Sensitivity and specificity data of exercise ECG testing is dependent upon the cohort of patients being studied: sensitivity is higher in patients with triple-vessel disease, and lower in patients with single-vessel disease.
Gender differences mean that exercise ECG is only moderately specific for the diagnosis of CHD in women.
The European Society of Cardiology (ESC) recommend the use of a risk-estimation system i.e. SCORE to calculate total risk estimation for asymptomatic patients >40 years of age without evidence of diabetes, chronic kidney disease, cardiovascular disease, or familial hypercholesterolemia. The assessment of a family history of premature CVD is recommended. A validated clinical score should be used in patients <50 years of age who have a family history of premature CVD in a first-degree relative.
In asymptomatic but high-risk adults (with diabetes, a strong family history of CVD, or when previous risk-assessment tests suggest a high risk of CVD), functional imaging or coronary CTA may be considered for cardiovascular risk assessment.
For people at low risk of cardiovascular disease, the potential harms of screening with exercise ECG is thought by some (including the US Preventative Service Task Force) to be equal to or exceed the potential benefits. For people at intermediate to high risk, current evidence is thought to be insufficient to assess the balance of benefits and harms of screening.
Therefore, the US Preventative Services Task Force recommends against screening for CHD with resting or exercise ECG in adults at low risk for CHD events.
Chou et al cite that exercise ECG screening has not been shown to improve patient outcomes and is instead associated with potential harms due to false-positive results leading to potentially unnecessary tests and procedures.
Overall in asymptomatic patients without a history of CHD, the potential harms of exercise ECG (which includes arrhythmias, acute MI, sudden cardiac death and harms of subsequent angiography or revascularisation procedures after abnormal test) are considered by many to exceed the screening benefit. However, literature examining the frequency of these harms is lacking.
There is no specific EBI patient guidance for this intervention.
However, we recommend using the BRAN principles (Benfits, Risks, Alternatives and do Nothing) when speaking with patients about this.
Further information on patient involvement in EBI can be found on the EBI for patients section.
WHEN LEFT(der.Spell_Dominant_Procedure,4) LIKE '%U194%’ AND (apcs.der_diagnosis_all like '%I20%’ OR apcs.der_diagnosis_all like '%I24%’ OR apcs.der_diagnosis_all like '%I25%’) AND isnull(APCS.Age_At_Start_of_Spell_SUS,APCS.Der_Age_at_CDS_Activity_Date) between 19 AND 120 THEN '2L_ExerciseECG’
WHEN OPA.Der_Procedure_All LIKE '%U194%’ AND isnull(OPA.Age_at_Start_of_Episode_SUS,OPA.Der_Age_at_CDS_Activity_Date) between 19 AND 120 THEN '2L_ExerciseECG'
Procedure codes (OPCS)
U194 Exercise electrocardiography
Diagnosis codes (ICD)
I201 Angina pectoris with documented spasm
I208 Other forms of angina pectoris
I209 Angina pectoris, unspecified
I240 Coronary thrombosis not resulting in myocardial infarction
I248 Other forms of acute ischaemic heart disease
I250 Atherosclerotic cardiovascular disease, so described
I251 Atherosclerotic heart disease
I252 Old myocardial infarction
I253 Aneurysm of heart
I254 Coronary artery aneurysm and dissection
I255 Ischaemic cardiomyopathy
I256 Silent myocardial ischaemia
I258 Other forms of chronic ischaemic heart disease
I259 Chronic ischaemic heart disease, unspecified
All diagnoses and procedure only if admitted as an inpatient solely for the
apcs.der_diagnosis_all not like '%C[0-9][0-9]%' and apcs.der_diagnosis_all not like '%D0%' and apcs.der_diagnosis_all not like '%D3%' and apcs.der_diagnosis_all not like '%D4%’
This code captures code in the ranges C00-C99, D00-D09 and D37-D48.
Age range: the codes use the following age ranges 0-18 for children and 19-120
— Private Appointment Exclusion
- NICE Guidance (2016) Chest pain of recent onset: assessment and diagnosis [CG95].
- Jonas D, Reddy S, Middleton J et al. Screening for cardiovascular disease risk with electrocardiography: an evidence review for the US preventative services task force. Rockville MD: Agency for healthcare research and quality. 2018.
- Jin J. Screening for cardiovascular disease risk with ECG. JAMA, 2018; 319:22.
- Koskinas K. Appropriate use of non-invasive testing for diagnosis of stable coronary artery disease. J Cardiology practice. 2014:12.
- Chou R. et al. Cardiac screening with electrocardiography, stress echocardiography, or myocardial perfusion imaging: advice for high-value care from the American College of Physicians. Ann Intern Med. 2015 Mar 17;162(6):438-47. doi: 10.7326/M14-1225.
- Juhani Knuuti, et al. ESC Scientific Document Group, 2019. ESC Guidelines for the diagnosis and management of chronic coronary syndromes: The Task Force for the diagnosis and management of chronic coronary syndromes of the European Society of Cardiology (ESC), European Heart Journal, Volume 41, Issue 44, 21 November 2020, Page 4242, DOI: doi.org/10.1093/eurheartj/ehz825
How up to date is this information?
Last revised December 2023
December 2023 - Coding updated. August 2022 - Coding updated