Background: Nonagenarians represent a growing population in the United States. Cardiac stress testing is commonly used for risk stratification in patients with chest pain. However, there is limited evidence on the benefits of stress testing in nonagenarians. Aims: The goal of this study was to investigate the utilization of cardiac stress testing in nonagenarian evaluated in outpatient clinics for chest pain, and to evaluate the incremental prognostic value of stress testing in this population. Methods: This is a retrospective observational study that included patients 90 years and above who presented for outpatient evaluation of chest pain. Referral for cardiac stress testing was captured using electronic health records. Patients were followed for one year. The associations between cardiac stress testing and subsequent cardiac catheterization, coronary revascularization, and myocardial infarction were evaluated using logistic regression models. Results: Between 2017 and 2021, 11763 patients 90 years and above presented to a clinic visit with a chief complaint of chest pain. There were 50.3% male, 61.4% White, 9.0% Black, 20.0% Hispanic, and 9.3% Asian. In this group, 320 (2.7%) underwent cardiac stress testing. Patients referred for testing had fewer cardiac risk factors, with a lower prevalence of hypertension, hyperlipidemia, and diabetes. At one year of follow-up, 6.9% of patients in the stress test group underwent cardiac catheterization, compared to 2.5% of patients in the no testing group (adjusted OR 2.87, 95% CI 1.81-4.57). Revascularization occurred in 0.63% patients in the stress testing group compared to 0.78% in the no testing group (adjusted OR 0.78, 95% CI 0.19-3.21). Myocardial infarction occurred in 3.4% in the stress testing group compared to 4.4% in the no testing group (adjusted OR 1.67, 95% CI 0.79-2.9). Conclusion: Among nonagenarians who underwent outpatient evaluation of chest pain, cardiac stress testing was associated with a significantly increased odds of subsequent cardiac catheterization, but no difference in revascularization or myocardial infarction. These observations suggest the clinical benefits of stress testing in nonagenarians may be limited.