Assessment of chest pain in a low risk patient: is the exercise tolerance test obsolete?

#### The bottom line A 55 year old man presents with chest pain that he has had for a few months. He is a keen cyclist and a non-smoker with normal blood pressure. He has a serum total cholesterol concentration of 6.1 mmol/L (with an high density lipoprotein cholesterol concentration of 1.5 mmol/L). The chest pain is anterior, poorly localised, mild, and intermittent, though sometimes associated with exercise. It generally resolves after a few minutes whether or not the patient continues to exercise. Examination and his resting 12 lead electrocardiograph are normal. Three international guidelines for the assessment of new onset of chest pain provide different advice about how an individual at low or medium likelihood of coronary artery disease should be investigated (table 1⇓). The American Heart Association1 and European Society of Cardiology2 advocate the exercise tolerance test or functional cardiac imaging. However, in 2010, the UK National Institute for Health and Care Excellence (NICE) took a new approach and recommended that, for patients who had a low likelihood of coronary artery disease, coronary artery calcium scoring should be the first line investigation, replacing the …