Temporal trends in the clinical utilization of cardiac imaging tests: 2008-2024

Over the past two decades, the range of noninvasive imaging modalities for evaluating suspected or established coronary artery disease (CAD) has expanded substantially. Yet how clinicians apply these anatomic and physiologic tests in real-world practice-across different age groups and CAD strata-remains poorly characterized.

We analyzed 71,987 patients who underwent noninvasive diagnostic and/or prognostic cardiac imaging between 2008 and 2024, including 28,671 undergoing coronary CT angiography (CCTA), 34,913 undergoing SPECT myocardial perfusion imaging (MPI), and 13,830 undergoing PET-MPI imaging. Patients were classified by age and presence or absence of known CAD, and temporal trends in test utilization were evaluated across modalities.

Over the study period, cardiac imaging utilization shifted profoundly, characterized by a steady increase in the use of CCTA and a corresponding progressive decline in SPECT-MPI. Among patients without known CAD, CCTA use rose across all age groups; by 2024, CCTA was the primary diagnostic test in 84% of patients <50 years, 81% of those 50-59 years, 73% of those 60-69 years, and 63% of those ≥70 years. In patients with known CAD, CCTA use also increased, though physiologic stress testing remained the predominant strategy in approximately three-fifths of known CAD patients.

Over 17 years, imaging practice at a tertiary center shifted markedly toward an anatomic-first approach in patients without known CAD, while physiologic testing remained common among those with established CAD. These real-world patterns both anticipated and align with contemporary guideline recommendations, reflecting evolving, age- and indication-specific imaging strategies in clinical care.