The ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) trial is currently randomizing patients with at least moderate ischemia on stress testing to a strategy of optimal medi- cal therapy alone (with coronary angiography reserved for failure of medical therapy) or routine cardiac catheterization followed by revascularization (when appropriate) plus optimal medical ther- apy. Before randomization, however, patients with normal renal function will undergo blinded computed tomography (CT) angiography to exclude them if significant left main CAD or no significant CAD is present. The writing group strongly endorses the ISCHEMIA trial, which will provide contemporary, high- quality evidence about the optimal strategy for managing patients with nonleft main SIHD and moderate-to-severe ischemia. In the majority of patients with suspected SIHD, noninvasive stress testing for diagnosis and risk stratification is the appropri- ate initial study. Importantly, coronary angiography is appropri- ate only when the information derived from the procedure will significantly influence patient management and if the risks and benefits of the procedure have been carefully considered and understood by the patient. Coronary angiography to assess cor- onary anatomy for revascularization is appropriate only when it is determined beforehand that the patient is amenable to, and a candidate for, percutaneous or surgical revascularization. In patients with abnormal, noninvasive stress testing for whom a diagnosis of CAD remains in doubt, many clinicians proceed to diagnostic coronary angiography. However, in some patients, multidetector CT angiography may be appropriate and safer than routine invasive angiography for this purpose. 