To evaluate whether individualized ramp protocols may be better than step protocols in patients ≥60 years of age referred for exercise testing, peak cardiopulmonary responses and accuracy in prediction of oxygen uptake (VO₂) for individualized ramp and step protocols (Bruce or modified Bruce) were compared. Twenty-four subjects (67 ± 3 years) with known or suspected coronary artery disease performed both tests in random order. Protocols were selected based on estimated exercise capacity using a pretest activity questionnaire. No differences were observed between peak VO₂ (19.3 ± 6.3 and 19.1 ± 6.4 ml/kg/min), heart rate (127 ± 15 and 126 ± 16 beats/min), rate–pressure product (24.0 ± 4.8 and 23.4 ± 4.9 beats/min × mm Hg × 10³) and anaerobic threshold (16.6 ± 3.7 and 16.0 ± 4.7 ml/kg/min) for the ramp and step protocols, respectively. The relation between measured submaximal VO₂ and American College of Sports Medicine (ACSM)-predicted VO₂ during the ramp protocol is demonstrated by the regression coefficient (β), where β = 0.92 (95% confidence intervals [CI] 0.85 to 0.99) and for the step protocols where β = 1.02 (95% CI 0.84 to 1.20). Peak cardiopulmonary responses in the elderly are similar during individualized ramp and step protocols when appropriately selected based on a pretest activity questionnaire. Both protocols appear to provide clinically reasonable estimates of VO₂ when gas exchange analysis is not used.