Exercise ECG (SECG) is one of several noninvasive test procedures routinely used to diagnose coronary disease presence and to estimate prognosis. Unfortunately, like all current noninvasive procedures used for this type of risk stratification, test accuracy is imperfect. A common approach to improve test sensitivity is to implement an additional modality, such as exercise myocardial perfusion imaging (MPI). However, the additional procedure adds cost, may lead to false-positive results that necessitate downstream testing, and, in the case of MPI, adds radiation exposure (≈11 mSv for rest-stress 99mTc sestamibi and ≈29 mSv for dual isotope 201Tl-99mTc sestamibi studies).1,2 Very few studies have examined the cost-effectiveness of using either SECG or MPI as the initial exercise test procedure to assess symptomatic women with suspected coronary disease. Risk stratification with SECG/MPI is considerably more difficult in women than men, in part because of a greater frequency of abnormal SECG, more soft-tissue attenuation on MPI (ie, breast artifacts), and, in general, a lower pretest risk of coronary disease.3 The likelihood of finding obstructive coronary disease in a woman seen for the initial evaluation of stable chest pain is strongly influenced by the character of chest pain (typical angina, atypical angina, nonspecific chest pain), age, and risk factors that are used to estimate the pretest risk of coronary disease and the likelihood of future cardiac events.3,4 Article see p 1239 The importance of considering the pretest coronary disease risk is illustrated by data from the Coronary Artery Surgery Study (CASS) registry.3 The prevalence of obstructive coronary disease in women referred for coronary angiography without a prior history of an acute coronary syndrome or revascularization was 72% in 401 women with typical angina, 36% in 1012 with atypical chest pain, and 6% in 1397 …