Real-World Practice of Exercise Electrocardiographic Stress Testing for the Evaluation of Chest Pain

BACKGROUND: The use of exercise electrocardiographic stress testing (EST) has declined because of concerns regarding its diagnostic accuracy. In Korea, where invasive coronary angiography (CAG) is readily accessible, the contemporary patterns of EST remain unclear. OBJECTIVES: To evaluate the current use of EST before elective CAG and its association with patient characteristics and angiographic findings. METHODS: This cross-sectional analysis included 2,517 patients enrolled between 2013 and 2023 in the nationwide multicenter KoRean wOmen's chest Pain rEgistry (KoROSE), all of whom underwent elective CAG for chest pain. The primary outcome was performance of EST before CAG. Multivariable logistic regression identified factors associated with undergoing EST. RESULTS: Of the 2,517 patients (median age: 64 years [IQR: 56-71 years]; 62.5% female), 1,470 (58.4%) underwent EST before CAG. EST was performed more frequently in men than in women (69.5% vs 51.7%; P < 0.001), and it was performed less frequently for patients with obstructive coronary artery disease (OCAD) than for those without OCAD (48.4% vs 65.3%; P < 0.001), a pattern consistent across sexes. Among patients with an intermediate pretest probability, 71.2% of the men and 54.1% of the women underwent EST (P < 0.001). Female sex was an independent negative predictor of undergoing EST, even after adjusting for age and clinical risk factors (adjusted OR: 0.60, 95% CI: 0.47-0.78, P < 0.001). CONCLUSIONS: In contemporary practice, EST is underused before elective CAG, particularly in women. Underuse of EST may contribute to incomplete ischemic assessment and under-recognition of alternative ischemic mechanisms, emphasizing the need for improved pre-CAG evaluation strategies.