Pharmacological stress echocardiography is reason- able for patients with a low pretest probability of Table 11. Stress Testing and Advanced Imaging for Initial Diagnosis in Patients With Suspected SIHD Who Require Noninvasive Testing Test Exercise Status ECG Interpretable Pretest Probability of IHD COR LOE References Able Unable Yes No Low Intermediate High Patients able to exercise* Exercise ECG X X X I A (114, 145 147) Exercise with nuclear MPI or Echo X X X X I B (91, 132, 148 156) Exercise ECG X X X IIa C N/A Exercise with nuclear MPI or Echo X X X X IIa B (91, 132, 148 156) Pharmacological stress CMR X X X X IIa B (153, 157, 158) CCTA X Any X IIb B (158 166) Exercise Echo X X X IIb C N/A Pharmacological stress with nuclear MPI, Echo, or CMR X X Any III: No Benefit C (155, 167, 168) Exercise stress with nuclear MPI X X X III: No Benefit C N/A Patients unable to exercise Pharmacological stress with nuclear MPI or Echo X Any X X I B (148 150, 152 156) Pharmacological stress Echo X Any X IIa C N/A CCTA X Any X X IIa B (158 166) Pharmacological stress CMR X Any X X IIa B (153, 157, 158, 169 172) Exercise ECG X X Any III: No Benefit C (91, 132, 148 156, 161) Other CCTA If patient has any of the following: a) Continued symptoms with prior normal test, or b) Inconclusive exercise or pharmacological stress, or c) Unable to undergo stress with MPI or Echo Any Any X IIa C (173) CAC score Any Any X IIb C (174) CAC indicates coronary artery calcium; CCTA, cardiac computed tomography angiography; CMR, cardiac magnetic resonance imaging; COR, class of recommendation; ECG, electrocardiogram; Echo, echocardiography; IHD, ischemic heart disease; LOE, level of evidence; MPI, myocardial perfusion imaging; N/A, not available; and SIHD, stable ischemic heart disease. 