ObjectiveTo compare the value of exercise testing and coronary angiography in the management of patients with effort angina.DesignA retrospective follow‐up study.SettingA university teaching hospital.PatientsFour hundred and thirty‐four patients with a history of angina, who developed pain or ST segment changes during an exercise test and who were followed‐up at up to nine years after their exercise test.InterventionsCoronary angiography was offered to patients for disabling angina only. Bypass surgery was generally offered to patients with multiple vessel coronary artery obstruction.Main outcome measurePatient survival.ResultsStepwise regression analysis based on the Cox proportional hazards model indicated that the decision to perform coronary angiography (P<0.001) and the amount of ST segment depression on exercise testing (P<0.01) were predictors of survival. With ST segment depression set at 1 mm and age set at 53.5 years (both sample median values) the probability of survival at five years was 86% in patients who did not undergo coronary angiography compared with 96% in patients who did undergo angiography. There were eight deaths in 59 patients who did not show any ST segment depression during the exercise test and who were treated medically without coronary angiography.ConclusionsCoronary angiography is a superior technique to exercise testing for detecting patients with effort angina who are at high risk of premature mortality. Coronary bypass surgery makes a big improvement in the chance of five‐year survival in such patients.