Do I Need a Stress Test? Why I Don't Order Them for Patients Without Symptoms

One of the most common conversations I have in the clinic starts with a patient who feels perfectly fine asking, "Doc, shouldn't we run a stress test just to make sure I'm not about to have a heart attack?" Sometimes their previous doctor ordered one every year like clockwork. Sometimes a close friend just had a scare. It's a reasonable thing to want, and hopping on a treadmill sounds like the obvious way to check. But for people without symptoms, the guidelines advise against routine stress testing, and the reason has less to do with cost than with what the test can and cannot see.

Key Findings & Takeaways

• What a stress test actually looks for: A stress test looks for ischemia, which is what happens when part of the heart muscle stops getting enough blood during exertion. That usually shows up only when a narrowing is severe, roughly 70% or more, and even then some real blockages pass the test. A normal result tells you less than most people assume.
• Where heart attacks actually come from: A large share of heart attacks don't come from those severe, long-standing narrowings. They come from softer cholesterol deposits in the artery wall, called plaque, that are mild or moderate in size, would sail through a stress test, and then suddenly tear open and form a clot. The test is looking for the wrong thing.
• What happens when the test comes back abnormal in someone healthy: In a person with no chest pain, no shortness of breath, and no limits on what they can do, an abnormal result is far more likely to be a false alarm than a real problem. I have sent people for an angiogram, a catheter procedure that images the arteries from the inside, off a worrying treadmill result and found nothing. That is not a harmless outcome. It means anxiety, radiation, and a procedure with real risks, for no benefit.
• Even finding a narrowing usually doesn't change what we do: Here is the part that surprises people. Suppose we did find one. In ISCHEMIA, the largest trial we have on this question, patients who already had significant blockages and a clearly abnormal stress test were sent either straight to stents or bypass, or to medication and lifestyle treatment alone. Over the following years, the invasive group was no less likely to die or have a heart attack. Opening the artery did relieve chest pain in the people who had chest pain. It did not prevent the heart attack. So when I am deciding whether to test someone who feels fine, the honest question is what I would do differently with the answer. Usually, nothing.
• What actually lowers your risk: Getting your LDL and ApoB cholesterol down (ApoB is a blood test that counts the cholesterol particles that do the damage, and it is worth asking for by name), keeping your blood pressure controlled, not smoking, and staying physically active. Those are the things with real evidence behind them, and none of them require a treadmill to tell you whether they are working.
• When a stress test is exactly the right call: Chest pressure or tightness when you exert yourself, new shortness of breath, or a real drop in what you can do before you have to stop. Those are reasons to call your doctor, and testing is appropriate then. There are also situations where a test makes sense even without symptoms: clearance before certain surgeries, known coronary disease, a new abnormal EKG, a high coronary calcium score, or a job that requires cardiac certification, like commercial driving or flying. If your doctor ordered a stress test, ask why before you cancel it. There is usually a reason.

If you feel well and exercise without symptoms, skipping the annual stress test is not cutting corners. It is what the evidence supports. This is general information rather than advice about your particular heart, so bring the question to your own cardiologist. And if something is genuinely new or different about how you feel, don't wait for the next annual visit to mention it.

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Reference Source: U.S. Preventive Services Task Force — Cardiovascular Disease Risk: Screening With Electrocardiography (recommends against resting or exercise ECG screening in asymptomatic low-risk adults; Grade D)

Journal Article: New England Journal of Medicine — Initial Invasive or Conservative Strategy for Stable Coronary Disease (ISCHEMIA)

Journal Article: Circulation — 2023 AHA/ACC Guideline for the Management of Patients With Chronic Coronary Disease

Journal Article: Journal of the American College of Cardiology — 2021 AHA/ACC Guideline for the Evaluation and Diagnosis of Chest Pain