Currently, the National Institutes of Health National Heart, Lung, and Blood Institute sponsored ISCHEMIA trial is under way and is comparing the effectiveness of a conserva- tive versus catheterization-based initial management strategy for patients with moderate severe ischemia. Several large single-center and multicenter registries have demonstrated consistently that both stress nuclear MPI and stress echocardiography provide incremental prognostic value beyond that provided by a standard ECG.115,272,299,305,307 315 The addition of imaging is manda- tory for patients who have an uninterpretable baseline ECG (including the presence of LBBB or ventricular pacing, LV hypertrophy, use of digitalis or electrolyte abnormalities, coexisting resting ST-segment abnormality, or preexcitation syndromes) and might be of value in patients with equivocal stress-induced316 ECG ST changes317 or an intermediate Duke treadmill score.316 Poornima et al, demonstrated that nuclear MPI has independent prognostic value even in pa- tients with low-risk Duke treadmill scores, but only if there is increased clinical risk, such as a history of typical angina, MI, diabetes mellitus, and advanced age.318,319 Similarly, infor- mation from exercise echocardiography appears to provide improved prediction of mortality among patients with low- risk Duke treadmill scores.311,318 From a large registry, the extent of ischemic myocardium as quantified by summed difference score by nuclear MPI has been shown to form an effective prognostic score for the prediction of cardiac mor- tality.320 Results from exercise nuclear MPI and exercise stress echocardiography appear to provide accurate estimates of the likelihood of death among men and women with suspected and known SIHD and for patients from different From a review of large single- and multicenter registries and meta-analyses,111,115,272 the following conclusions can be made: 1. 