An additional limitation of these models is that they were derived from populations of patients #70 years of age. Yet another drawback is that they perform less well in women, in part because the prevalence of obstructive CAD is lower in women than in men. As shown in Table 9, the Diamond- Forrester model substantially overestimates the likelihood of CAD compared with the prevalence observed in the WISE After integrating data from the clinical evaluation, model predictions, and other relevant factors to develop a probabil- ity estimate, the clinician must then engage the patient in a process of shared decision making, as noted in Section 1.8, to determine whether further testing is warranted. 2.2. Noninvasive Testing for Diagnosis of IHD 2.2.1. Approach to the Selection of Diagnostic Tests to Diagnose SIHD Functional or stress testing to detect inducible ischemia has been the gold standard and is the most common noninva- sive test used to diagnose SIHD. All functional tests are designed to provoke cardiac ischemia by using exercise or pharmacological stress agents either to increase myocardial work and oxygen demand or to induce vasodilation-elicited heterogeneity in induced coronary flow. These techniques Table 8. Conditions Provoking or Exacerbating Ischemia Increased Oxygen Demand Decreased Oxygen Supply Noncardiac Noncardiac Hyperthermia Hyperthyroidism Sympathomimetic toxicity (ie, cocaine use) Hypertension Anxiety Arteriovenous fistulae Anemia Hypoxemia Pneumonia Asthma Chronic obstructive pulmonary disease Pulmonary hypertension Interstitial pulmonary fibrosis Obstructive sleep apnea Sickle cell disease Sympathomimetic toxicity (ie, cocaine use, pheochromocytoma) Hyperviscosity Polycythemia Leukemia Thrombocytosis Hypergammaglobulinemia Cardiac Cardiac Hypertrophic cardiomyopathy Aortic stenosis Dilated cardiomyopathy Tachycardia Ventricular Supraventricular Aortic stenosis Hypertrophic cardiomyopathy Significant coronary obstruction Microvascular disease Modified from Gibbons et al.7 Table 9. 