The cumulative published literature dealing with the most frequently utilized noninvasive cardiac stress imaging modalities (radionuclide myocardial perfusion scintigraphy and echocardiography) was reviewed to gain insight on their comparative diagnostic accuracies. To be included, studies had to be performed in conjunction with exercise or a commonly used intravenous pharmacologic stress agent (dipyridamole, adenosine or dobutamine) and had to report temporally related coronary angiography findings. A total of > 75 studies were included, involving > 7,000 patients. Exercise single-photon emitted computed tomographic (SPECT) scintigraphy was more sensitive than exercise echocardiography for detecting coronary artery disease (CAD), localizing it to the proper coronary artery distribution and correctly identifying the presence of multivessel CAD. Adenosine, dipyridamole, and dobutamine provided similar diagnostic accuracy when performed in conjunction with SPECT scintigraphy, and all were more accurate than dobutamine echocardiography. Clinical specificity was similarly high with adenosine SPECT, dipyridamole echocardiography, and exercise echocardiography, and lower with exercise SPECT. Normalcy rate was high for exercise SPECT and similar to clinical specificity for echocardiography.