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Positive Exercise Test Next Steps — EECC MCQ

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EasyCoronary Artery DiseasePositive Exercise Test Next StepsEECC

A 50-year-old man with stable angina has a positive exercise test at 8 METs with 2 mm horizontal ST depression in leads V4-V6 at peak exercise. His echocardiographic LVEF is 60%. What is the next investigation?

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Correct answer: B — Invasive coronary angiography or non-invasive anatomical/functional imaging (CTCA or stress imaging) to confirm and characterise the extent of CAD — the exercise ECG shows inducible ischaemia warranting further evaluation

A positive exercise ECG (≥1 mm horizontal or downsloping ST depression at ≥80% APMHR) in a patient with anginal symptoms warrants further investigation to characterise CAD anatomy and guide management. The 2024 ESC CCS Guidelines recommend: (1) CTCA for anatomical assessment (preferred for low-intermediate PTP); (2) stress imaging (echo, CMR, SPECT/PET) for functional assessment (particularly useful when CAD is known or PTP is intermediate-high); (3) invasive coronary angiography with FFR/iFR if non-invasive testing suggests significant CAD or is inconclusive. The exercise ECG has limited specificity (~70%), so confirmatory testing reduces false-positive driven unnecessary procedures. The 2 mm depression and moderate exercise capacity (8 METs) suggest moderate ischaemic burden.

Reference: ESC (2024): CCS Guidelines