Exercise Prescription without Stress Test: Practical Alternatives

Cardiopulmonary exercise test (CPET) is considered the gold standard for evaluating cardiorespiratory fitness, stratifying cardiovascular risk, and guiding individualized exercise prescription in cardiac rehabilitation (CR). However, CPET is not always feasible due to limited resources, contraindications, or patient-related factors such as frailty, multiple comorbidities, impaired balance with an increased risk of falls, and poor exercise tolerance. Therefore, practical alternatives are required to ensure safe and effective exercise prescription in these populations. This narrative review summarizes alternative assessment tools and exercise strategies when CPET cannot be performed. Field-based walk tests, including the 6-minute walk test (6MWT) and incremental shuttle walk test (ISWT), as well as various step tests, provide feasible approaches to estimate aerobic capacity and monitor functional changes. Although these methods have limitations in precision compared with CPET, they offer clinically meaningful information for exercise prescription and follow-up. In addition, frailty assessments such as the Short Physical Performance Battery, Timed Up and Go test, and handgrip strength can complement functional evaluation, particularly in older adults. Exercise prescription without CPET should adopt a conservative and individualized approach. Initial low-intensity exercise with gradual progression is recommended, with close monitoring for symptoms and adverse responses. When center-based CR is not feasible, home-based programs with patient education and cautious intensity progression can be considered. In conclusion, although CPET remains the standard, alternative functional assessments combined with prudent clinical judgment allow safe and effective CR even in its absence.