What is the best test for a patient with classic angina?

Symptoms that suggest myocardial ischemia raise two questions: does the patient have severe, hemodynamically obstructive coronary artery disease, and is he or she at risk for premature death or an early, major nonfatal cardiac event? Noninvasive cardiac testing may help with the first question in patients with an intermediate risk of coronary artery disease, and with the second question in patients with either an intermediate or a high risk of disease. Although the diagnostic value of noninvasive tests may be overestimated owing to referral bias, these tests are powerful when used for prognostic purposes. In patients with a normal resting electrocardiogram and no prior revascularization, a regular exercise stress test without imaging should suffice. However, no randomized trials have been done to determine if this strategy leads to better outcomes than with empiric therapy.