Since our last review of the prognostic accuracy of stress myocardial perfusion SPECT,1 numerous advances in the field have promulgated tremendous (and oft characterized as excessive) growth in the utilization of nuclear cardiology services over the past few decades.2-4 The overall procedural utilization for stress myocardial perfusion imaging (MPI) reached its height in ~2008 with over 10 million procedures performed and Medicare expenditures in excess of $1 billion.3 Although many have focused culpability for growth on high reimbursement levels, the published evidence base also figured prominently in supporting healthcare coverage decisions and promoting utilization. Figure 1 plots the relationship between publications on nuclear cardiology and Medicare payments to physicians for stress MPI.