BMJ Open 2:e000508 doi:10.1136/bmjopen-2011-000508
  • Cardiovascular medicine
    • Research

Treading carefully: a qualitative ethnographic study of the clinical, social and educational uses of exercise ECG in evaluating stable chest pain

  1. Gene Feder1
  1. 1Academic Unit of Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
  2. 2School of Nursing and Midwifery Studies, Cardiff University, Cardiff, UK
  3. 3Department of Epidemiology and Public Health, University College London, London, UK
  4. 4Department of Cardiology, Barts and the London NHS Trust, The London Chest Hospital, London, UK
  1. Correspondence to Dr Helen Cramer; helen.cramer{at}
  • Received 20 October 2011
  • Accepted 21 December 2011
  • Published 8 February 2012


Objective To examine functions of the exercise ECG in the light of the recent National Institute for Health and Clinical Excellence guidelines recommending that it should not be used for the diagnosis or exclusion of stable angina.

Design Qualitative ethnographic study based on interviews and observations of clinical practice.

Setting 3 rapid access chest pain clinics in England.

Participants Observation of 89 consultations in chest pain clinics, 18 patient interviews and 12 clinician interviews.

Main outcome measure Accounts and observations of consultations in chest pain clinics.

Results The exercise ECG was observed to have functions that extended beyond diagnosis. It was used to clarify a patient's story and revise the initial account. The act of walking on the treadmill created an additional opportunity for dialogue between clinician and patient and engagement of the patient in the diagnostic process through precipitation of symptoms and further elaboration of symptoms. The exercise ECG facilitated reassurance in relation to exercise capacity and tolerance, providing a platform for behavioural advice particularly when exercise was promoted by the clinician.

Conclusions Many of the practices that have been built up around the use of the exercise ECG are potentially beneficial to patients and need to be considered in the re-design of services without that test. Through its contribution to the patient's history and to subsequent advice to the patient, the exercise ECG continues to inform the specialist assessment and management of patients with new onset stable chest pain, beyond its now marginalised role in diagnosis.


  • To cite: Cramer H, Evans M, Featherstone K, et al. Treading carefully: a qualitative ethnographic study of the clinical, social and educational uses of exercise ECG in evaluating stable chest pain. BMJ Open 2012;2:e000508. doi:10.1136/bmjopen-2011-000508

  • Contributors GF, HH and ADT designed the programme of research in which this study is embedded. GF and KF had the idea for the qualitative component of the study. HC and ME undertook the interviews, observations, analysed and interpreted the data, which were discussed with KF and GF. HC wrote the first draft. GF, KF, HH, MJSZ, ADT and RJ revised the article for important intellectual content. All members of the team gave final approval of the version published. GF and HC are the guarantors. All contributors had full access to all the data in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis.

  • Funding This work is supported by the National Institute for Health Research (NIHR) programme grant reference RP-PG-0407-10314 (NIHR, Room 132, Richmond House, 79 Whitehall, London SW1A 2NS, UK). The NIHR had no involvement in the research process or writing of this article.

  • Competing interests All authors have completed the unified competing interest form at (available on request from the corresponding author) and declare (1) no financial support for the submitted work from anyone other than their employer, except ADT who previously had support from NICE for work on guideline development; (2) no financial relationships with commercial entities that might have an interest in the submitted work; (3) no spouses, partners or children with relationships with commercial entities that might have an interest in the submitted work and (4) no non-financial interests that may be relevant to the submitted work.

  • Patient consent We used our own ethics approved consent form.

  • Ethical approval The study was approved by the West London NHS multicentre research ethics committee (08/H0709/85).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement There is no additional data available.

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