Cardiovascular disease is the number one killer of Americans. Although the clinician has many options available to evaluate and diagnose coronary artery disease (CAD) before the patient has experienced a major cardiac event, the first process in the evaluation of CAD is a thorough history and physical examination. If disease is suspected at this point, to select further testing the clinician should keep in mind the principles of Bayesian analysis.¹ Pretest probability is paramount in detecting true disease.

As discussed in earlier chapters, a plain exercise treadmill test (ETT) is useful in patients who have a normal electrocardiogram (ECG) and the ability to exercise. Many more patients will not fit this category and will require further testing with imaging modalities. Imaging testing using stress echocardiography and stress nuclear studies is most useful in patients with intermediate cardiac risk. Using imaging we can detect ischemic heart disease, assess the severity of known lesions, evaluate the effects of pharmacologic therapy, and assess overall work capacity, all information vital in establishing diagnosis and prognosis.