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The unsustainable rising cost of healthcare has thrust us into an era in which the use of medical tests must be of proven clinical value. For diagnostic cardiac tests, this means determining if testing leads to some combination of improving outcomes or cost savings— the new era of ‘‘value-based imaging.’’ Notably, in this regard, it is not the result of a test which changes outcomes, but the management that occurs based on that result. Radionuclide stress myocardial perfusion imaging (MPI) has been a routine part of the cardiology landscape for approximately 40 years. Its use during this time emerged from its proven ability to predict patient outcomes. How might this test fair best in the ‘‘new marketplace’’ in which the use of tests will now depend on their ability to alter patient outcomes? The answer to this question is being affected by three important trends. First, since the late 1960s, the clinical presentation of coronary artery disease has markedly changed. While still the nation’s leading cause of death, the annualized mortality rate of heart disease has decreased by 70%, myocardial infarction is both less frequent and less severe, and even the frequency of angina is diminishing. From 1991 to 2009, we noted a concomitant marked decline in the frequency of inducible myocardial ischemia on SPECT-MPI among diagnostic patients in the Cedars-Sinai experience, falling from a frequency of 30% in 1991 to only 5% in 2009. Recent experiences in other large datasets, such as the patients recruited into the WOMEN and PROMISE trials have also demonstrated a concurrent low frequency of inducible myocardial ischemia as well as of obstructive CAD. Further, recent reports have also been documented that the likelihood of obstructive CAD is now far lower than that predicted by the standard approaches which are based on data from the 1970’s. Thus, a large majority of SPECT-MPI studies within diagnostic populations can now be expected to be normal. While the finding of a normal SPECT-MPI study without anatomic imaging may reduce referral to invasive coronary angiography (ICA), for the most part, it has little effect on patient management. Second, studies involving concomitant SPECT-MPI and coronary artery calcium (CAC) scanning have revealed that among patients referred for radionuclide stress testing, the frequency of abnormal CAC studies among patients with normal nuclear studies is quite high. In our earliest experience in this regard, among 1,119 patients with normal SPECT-MPI studies, 78% had evidence of CAC and in[30% of patients, the CAC score was[400, indicative of extensive atherosclerosis. A limitation of radionuclide MPI-stress tests in general—is their inability to detect subclinical atherosclerosis, which is common among patients who are referred for cardiac stress testing. If the report were to include the presence and amount of CAC, i.e., adding anatomic imaging, greater change in management may follow. Further, there is increasing awareness that SPECT-MPI frequently underestimates the extent of obstructive CAD and may misclassify patients with angiographic highrisk disease. Knowledge of the presence of extensive coronary calcification could improve these assessments by better establishing the pre-scan likelihood of CAD as well as of high-risk CAD. Reprint requests: Daniel S. Berman, MD, FACC, Department of Imaging, Cedars-Sinai Medical Center, Cedars-Sinai Heart Institute, Los Angeles, CA; bermand@cshs.org J Nucl Cardiol 2016;23:939–41. 1071-3581/$34.00 Copyright 2016 American Society of Nuclear Cardiology.

Value-based imaging: Combining coronary artery calcium with myocardial perfusion imaging