I don’t think I would call it “a raging debate,” but there certainly is disagreement about how best to evaluate a patient with stable chest pain. Stable chest is that which is highly suspicious for coronary artery disease yet is responsive to rest or nitroglycerin. I’m not referring to coronary angiography, the definitive diagnostic procedure, but rather the test a patient has to “flunk” before a coronary angiogram is done.
When a patient presents to his doctor with chest pain, the doctor has two options from which to decide if more invasive diagnostic investigation is necessary. Those two options are:
CCTA: Coronary Computed Tomographic Angiography
or
Treadmill Functional Stress Test
A few months ago, DrGOpines.com published an article touting the successes of CCTA for patients with “stable chest pain”—that which is relieved quickly by rest or sublingual nitroglycerin and is not progressively getting worse. It has a 96% diagnostic accuracy and is non-invasive, but has limitations that advocates of functional stress testing find troublesome.
Functional stress testing is the old treadmill test. The patient walks on the treadmill while connected to an EKG. Changes in the EKG that are diagnostic for lack of oxygen to the heart (ischemia) tell the doctor a significant blockage is present. As a result, a heart catheterization is done to locate the blockage and determine its severity.
The author of my reference is a functional stress test advocate. He says that functional testing gives more valuable information about the blockage and the effect it has on the heart with maximum physical activity. He also points out the similarity in “end points” between the two tests.
In a trial of 10,000 patients, half had CCTA, and the other half had functional stress testing. The patients were observed for two years to see who had an end point of MI, unstable angina, death, or a procedural complication. In the CCTA group 3.3% of patients had an end point, while in the functional stress testing group 3.0% had an endpoint. Almost the same. No diagnostic difference was observed. CCTA pts. had a higher rate of invasive coronary angiography and coronary bypass surgery than functional stress testing because CCTA merely identified a blockage but did not show ischemia or heart muscle dysfunction. CCTA just tells you CAD is present. It tells you nothing about how, or even if, CAD is affecting cardiac function.
For patients with worsening chest pain, the situation needs to be evaluated quickly. Here, again, functional stress testing excels. Ischemia, that CCTA misses, can be seen through the EKG changes caused by physical stress.
The costs of CCTA are greater than for functional stress testing because it leads to greater frequency of invasive coronary angiography, stents, and CABG. For a patient to have invasive diagnostic studies, whichever of the two is done, has to be positive (abnormal). One procedure might be positive more often than the other, but the final outcome for the two procedures differs little.
Reference: Mandrola JM. The Case for Functional Stress Testing Over CT. Medscape 2026 February 17.
