For the exercise- capable patient with a normal baseline ECG, the decision to perform imaging with nuclear or echocardiographic tech- niques along with stress ECG should be based on many factors, including the likelihood of garnering substantial incremental prognostic information that is likely to alter clinical and therapeutic management. Estimates of cost-effectiveness of various testing strategies in symptomatic patients have been used to inform responses to rising healthcare costs. However, to be of value, estimates of cost-effectiveness must use contemporary estimates of effec- tiveness that incorporate considerations of disease prevalence and test accuracy. Furthermore, costs must reflect not only the index test but also the episode of care and the longer-term induced costs and outcomes of diagnosed and undiagnosed SIHD. Ideally, these data would be derived from RCTs or registries designed to compare the effectiveness of testing strategies and observed associated costs. However, in the interim until such evidence is available, mixed methods and decision analytic models provide general estimates of the cost-effectiveness of various forms of testing. Mixed methods use observational evidence of index and downstream proce- dures, hospitalization, and drug costs and apply cost weights to estimate cumulative costs,128 130 whereas decision analytic models simulate clinical and financial data.131 137 Regardless of the approach, inherent assumptions and uncertainties with regard to the data and incomplete consideration of risks and benefits require that such calculations be considered as In most studies, stress imaging is estimated to provide a benefit over exercise ECG at a reasonable cost, commensu- rate with accepted values for cost effectiveness (ie, at the threshold for economic efficiency of ,$50 000 per added year of life), a result driven primarily by more frequent angiography and adverse cardiovascular events for those with a negative exercise ECG. 