Introduction

The prevalence of angina is high in the general population, and increases with age in both sexes.1 New onset, stable chest pain among patients without known coronary artery disease (CAD) is a common clinical problem that results in approximately four million stress tests annually in the USA.2 Significant variations in features at presentation and diagnostic strategies are well-documented between both European countries and the USA, and may be related to differences in healthcare systems, access to testing technologies and risk tolerance.2–4 Furthermore, variation may be explained by the fact that limited information on health-related outcomes exists in this stable, undiagnosed population and there is little consensus about which test is preferable or even when one is required.5–7 In fact, major US and European guidelines differ fairly substantially in their basic approaches. The discrepancy between guidelines also differs significantly from other areas in cardiology (ie, therapy for acute coronary syndromes or chronic heart failure), where general consensus exists largely based on the availability of randomised clinical trial data. To this point, current guidelines for imaging stable chest pain of suspected cardiac aetiology do not yet incorporate recent randomised trials comparing functional versus anatomical testing strategies.8 ,9

Non-invasive test selection remains a common but challenging decision for many clinicians, and a controversial topic for practice guidelines. The aims of the current paper are to provide a concise approach to non-invasive test …