I read the recently published report “Cardiologist Concordance With the American College of Cardiology Appropriate Use Criteria for Cardiac Testing in Patients With Coronary Artery Disease,” by Lin et al, and would like to comment on a surprisingly forgotten issue in today’s cardiology, which was not the specific focus of this report: appropriate selection between stress-testing methods, which may be even more relevant than appropriateness of cardiac testing per se.

Approximately 10 million stress scintigraphic tests (single-photon emission computed tomography [SPECT]) are performed yearly in the United States. Exercise or pharmacologic SPECT in my European Union country has a hospital reimbursement fee of €480, while stress echocardiography is reimbursed at €124, and similar reimbursements ratios (approximately 4:1) may be grossly extrapolated across all European Union nations and the United States.

The 2 types of imaging stress tests have pros and cons, so that for specific subsets of patients, 1 may be better than the other, but they are substantially equivalent as diagnostic and prognostic tools for most patients. Moreover, the selected use of ultrasound contrast media for cavity opacification makes 100% of modern stress echocardiographic studies feasible and well interpretable, a significant previous limitation of echocardiography.

This happens ahead of the widespread urge to cut world health costs and a clear European Atomic Energy Community directive compelling the use of nonradiating diagnostic methods in medicine when they can be used in substitution for methods using ionizing radiations.

Still, there remains an irrational push toward the use of SPECT in cardiac stress imaging, which is not justified when a less costly alternative exists and is readily available at the bedside.

So why is there essentially no shift from SPECT to stress echocardiography? The answers are many, and reducing this topic to a battle of pride and power between nuclear and echocardiographic physicians seems illogical and probably worth more attention from competent regulatory and paying bodies. That would lead to savings of millions of dollars and euros and to significant environmental benefit, dedicating more resources to other evidence-based interventions.