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When cardiac stress testing is ordered prior to noncardiac surgery, the optimal test modality is unknown. Therefore, we conducted this study to compare the diagnostic accuracy of dobutamine stress echocardiography (DSE) and single-photon emission computed tomography (SPECT) in a representative sample of patients undergoing noncardiac surgery without an existing diagnosis of coronary artery disease (CAD). The predicted accuracy of DSE was greater than that of SPECT in around 60.5% of cases above the current guideline-recommended risk threshold. In this population, DSE is likely to be more accurate than SPECT in the diagnosis of obstructive CAD. To the extent that making a diagnosis of obstructive CAD changes the decision to pursue noncardiac surgery, DSE likely represents a more efficient testing modality. However, in the range of pretest probabilities among this population, positive results from either test are more likely to represent false positives than true positives.