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Background: The incidence of coronary artery disease is increasing, resulting in a concurrent rise in cardiac stress testing which usually includes an exercise (ETT) or chemical stress test (CST) with nuclear imaging (SPECT). CST with imaging is recommended for those with the inability to exercise, a left bundle branch block (LBBB) or a paced rhythm at baseline. However, the proportionate use of CST with SPECT appears to be on the rise. The purpose of our study is to assess the frequency of ETT vs. CST with SPECT over the last 10 years.Methods: This is a retrospective chart review of 854 adult patients at Charleston Area Medical Center (CAMC) who had a CST or ETT with SPECT from January 1, 2007 - April 30, 2016. The frequency of both stress tests, along with patient demographics, physical capabilities, the reason for performing the test, test results and 6 month outcomes were recorded.Results: The proportion of ETT with SPECT between 2007-2008 was 70.4% (138 of 196) which decreased to 37.7% (75 of 199) between 2015-2016. However, within the same time frame the proportion of CST with SPECT increased from 29.6% (58 of 196) to 62.3% (124 of 199). In patients who had CST, 4.2% (14 of 311)had a LBBB, 9.7% (32 of 331) had a paced rhythm, 13.0% (43 of 331) had reported inability to exercise and 76.3% (171 of 331) had reported ability to ambulate without assistance. For 70.7% (234 of 331) patients, there was no reported reason for choosing CST over ETT with SPECT. Regadenoson was the vasodilator used most frequently for CST. When comparing outcomes in patients who had stress tests with SPECT, 8.8% (29 of 331) of patients who had CST versus 6.3% (33 of 523) who had ETT needed cardiac catheterization (p = 0.18) within 6 months, while 2.4% (8 of 331) of the CST patients versus 1.9% (10 of 523) of ETT patients (p=0.62) required revascularization within 6 months. In patients who had ETT, 81.8% (421 of 523) achieved greater than 85% maximum heart rate for age and 90.4% (473 of 523) achieved greater than 80% maximum heart rate for age.Conclusion: There has been a marked increase in CST with SPECT performed at CAMC between 2007-2016. While most patients may have the physical capacity and baseline EKG characteristics to qualify for an ETT with SPECT, a clear explanation for this pattern remains unknown. A possible analysis of changes in patient characteristics over this time may provide some insight into this trend.