Use of invasive coronary angiography as a first test is not cost-effective in patients with a pretest probability ,75%.139,140 Finally, it is important to note that as the reimbursement for stress imaging decreases (it is now less than half the value used in older studies), the relative cost-effectiveness (dollars/quality-adjusted life-year saved) of stress imaging is more favorable than that of exercise ECG, and the comparative advantage of lower- to higher-cost imaging procedures is minimized. The cost-efficiency of CCTA is less well studied but also depends on disease prevalence.139,140 Data conflict as to whether patients undergoing CCTA as initial imaging modal- ity are less or more likely to undergo invasive coronary angiography or revascularization, although it appears that they have similar or lower rates of adverse cardiovascular events.128,130,141,142 As a result, CCTA performed alone or in combination with functional testing minimizes adverse car- diac events, maximizes quality-adjusted life-years,140,143 and is estimated to be cost-effective. Although data on cost-effectiveness and patient satisfac- tion for CMR are limited, evidence suggests that CMR can improve patient management. The German Pilot/European Cardiovascular Magnetic Resonance (EuroCMR) registry of 11 040 consecutive patients evaluated for cardiomyopathy, ischemia, and myocardial viability found that CMR satisfied all requested imaging needs in 86% of patients so that no further imaging was required.144 In the 3351 stress CMR cases, invasive angiography was avoided in 45%, compared with 18% in patients who underwent nuclear imaging. 2.2.2. Stress Testing and Advanced Imaging for Initial Diagnosis in Patients With Suspected SIHD Who Require Noninvasive Testing: Recommendations See Table 11 for a summary of recommendations from this section. 2.2.2.1. Able to Exercise Class I 1. 