Health jurisdictions across the world are troubled by the same topic—how the imaging component of the health budget can be spent wisely. Contributors to this problem are the ageing population, apparently limitless demand for imaging, and increasing sophistication and expense of imaging and treatment. Perhaps in no space is this more challenging than cardiovascular imaging, the growth of which has exceeded the overall growth of medical costs over the last decades.1 Part of the response to the disconnect between the growth in imaging and its value in North America has been the development of appropriate use criteria (AUC). Although the initial application of AUC were not directed towards cardiovascular imaging,2 the initial AUC for transthoracic and transoesophageal echocardiography were launched in 2007 and redefined in 2011,3 and similar situations have occurred for Single Photon Emission Computed Tomography (SPECT) and cardiac CT. The concept of appropriate use has had an extraordinary influence on the relationship between patients, physicians, administrators and insurance companies over the last decade.

AUC differ importantly from guidelines in that they are developed by consensus.4 A potential question, therefore, is whether they are necessarily correct. The study reported by Bhattacharyya et al,5 appears somewhat encouraging in this respect. Inappropriate stress echocardiograms had a low risk of cardiac events, similar to results found in Italy by Cortigiani et al,6 and in …