Background Exercise ECG testing is a widely used, noninvasive tool for detecting obstructive coronary artery disease (OCAD). However, its diagnostic performance is often limited by low specificity, leading to false-positive results and unnecessary invasive procedures. Objective This study aims to assess the potential of combining the Selvester QRS score with exercise ECG to enhance diagnostic specificity for OCAD in patients with suspected stable angina. Methods This retrospective study included 203 patients who presented with chest pain, underwent exercise ECG and were assessed for OCAD by coronary angiography or computed tomography angiography. Receiver operating characteristic analysis identified the optimal Selvester QRS score cutoff and assessed the diagnostic performance of exercise ECG and the combined model. Multivariable logistic regression was performed in the exercise ECG positive and negative groups. Results Of the 203 patients, 116 were diagnosed with OCAD. The optimal Selvester QRS score cutoff was >= 3, with a sensitivity of 83.6% and a specificity of 93.1%. The combination of a positive exercise ECG and a Selvester QRS score >= 3 achieved the highest specificity (98.9%). Regression analyses showed that Selvester QRS score >= 3 was an independent predictor of OCAD, even in patients with negative exercise ECG results (adjusted odds ratio: 7.018; P < 0.001). Conclusion The Selvester QRS score can improve the specificity of the exercise ECG in detecting OCAD in patients with suspected stable angina. This approach has the potential to reduce false positives and unnecessary invasive procedures by improving risk stratification. Copyright (c) 2025 Wolters Kluwer Health, Inc. All rights reserved.