Utility of Routine Exercise Stress Testing among Intermediate Risk Chest Pain Patients Attending an Emergency Department Jaimi H. Greenslade, PhD a,b,c* , William Parsonage, DM, MRCP, FRACP a,b,c , Ariel Ho b , Adam Scott, PhD a,c , Emily Dalton, BSc, BNursing a , Christopher Hammett, MBchB, FRACP, FCSANZ a , Anthony F.T. Brown, MBChB, FRCP, FRCSEd, FACEM, FCEM a,b , Kate Parker, BNursing, BHSci a , Louise Cullen, MBBS, FACEM a,b,c a Royal Brisbane and Women’s Hospital, Herston, Qld, Australia b University of Queensland, St Lucia, Qld, Australia c Queensland University of Technology, Brisbane, Qld, Australia Received 13 October 2014; received in revised form 25 March 2015; accepted 27 March 2015; online published-ahead-of-print 2 May 2015 Background To assess the utility of routine exercise stress testing (EST) in patients at intermediate risk of acute coronary syndrome (ACS) according to the Heart Foundation of Australia/Cardiac Society of Australia and New Zealand (HFA/CSANZ) guidelines. Method Prospective observational study of patients presenting to the Emergency Department (ED) with chest pain suggestive of ACS between November 2008 and July 2014. Participants included 1205 patients who pre- sented to the ED with chest pain suggestive of ACS and who met the HFA/CSANZ intermediate risk criteria. The outcome was diagnosis of ACS occurring on presentation or within 30 days of presentation to the ED. ACS included acute myocardial infarction and unstable angina pectoris. Results Twenty (1.66%) of the intermediate risk patients were diagnosed with ACS. Of the 777 patients who underwent EST, eight had ACS. EST identified all ACS cases except for one patient with a negative test, who was ultimately diagnosed with ACS following angiography. 164 patients deemed inappropriate to undergo EST underwent an alternative form of objective testing, of which 12 were positive for ACS. 264 patients underwent no objective testing. Conclusion EST stratifies intermediate risk patients to a near zero short-term risk of ACS. However, the overall yield of EST within this group of patients is extremely low. Intermediate risk patients with normal zero and six hour biomarkers have a very low probability of ACS, and over half of these patients ultimately diagnosed with ACS in this group were deemed unsuitable for EST anyway. Future research should focus on the identifica- tion of patients who do not require EST and the inclusion of routine EST within the HFA/CSANZ guidelines should be reconsidered. Keywords Exercise stress test  Acute coronary syndrome  Objective testing © 2015 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier Inc. All rights reserved. *Corresponding author at: c/o Department of Emergency Medicine, Royal Brisbane and Women’s Hospital, Butterfield Street, Herston, Queensland, 4072, Australia. Tel.: +61736466262, Email: j.greenslade@psy.uq.edu.au Heart, Lung and Circulation (2015) 24, 879–884 1443-9506/04/$36.00 http://dx.doi.org/10.1016/j.hlc.2015.03.025 ORIGINAL ARTICLE