Physiological changes in older adults, including alterations in cardiac output through various mech- anisms, muscle loss and deconditioning, neuropathies, lung disease, and degenerative joint disease, make stress testing more difficult. Thus, many elderly patients are incapable of responding to graded increases in workload as required by standard exercise ECG protocols.118,1151 For patients who are unable to exercise, pharmacological stress imaging is indi- cated. Although the majority of investigations have focused on prognosis by markers of ischemia in the elderly, the results generally reveal a similar accuracy of testing when compared with younger individuals presenting with SIHD.1152 1155 Baseline ECG changes, arrhythmias, and LV hypertrophy, which are more common in older adults who have accumu- lated cardiac comorbidities, also limit the value of stress testing.1156,1157 The higher prevalence of SIHD in older adults results in more tests that are falsely negative, and the prognostic value of the Duke treadmill score in older adults might be limited.1158 Data based on RCTs to guide therapy in older adults are relatively sparse because of the common exclusion of older patients from early clinical trials. Several studies have shown less frequent use of evidence-based therapies in older adults, such as early invasive procedures, anticoagulants, beta block- ers, and glycoprotein IIb/IIIa inhibitors.1156,1159,1160 The find- ings are likely related to several factors. Pharmacotherapy is more difficult in older adults because of changes in drug bioavailability and elimination. Drug drug interactions are more common because of polypharmacy. A more conserva- tive approach to coronary angiography is often appropriate given the higher risk of contrast-induced nephropathy in older adults.1161 Moreover, the risks of morbidity and mortality associated with CABG are increased in older adults. 