This review examines the diagnostic and prognostic performance of the standard exercise treadmill test (ETT) in comparison to stress imaging procedures. This topic is timely and relevant due to increasing healthcare expenditures and the substantially lower cost of the ETT.The most important goal of noninvasive testing is to identify patients with left main or three-vessel coronary artery disease (CAD) or severely reduced left ventricular ejection fraction (LVEF) less than 35%. These patient subsets demonstrate a survival advantage when treated with coronary artery bypass grafting (severe CAD) or a defibrillator (LVEF <35%). This benefit is not present for patients with one-vessel or two-vessel CAD or preserved LVEF. For patients who have a normal resting ECG, studies have shown that the standard ETT is as accurate as imaging for identifying these high-risk patients. Outcome of patients with a low-risk exercise treadmill score is excellent.The standard ETT should be the initial test in patients presenting for evaluation of CAD with the following characteristics: (1) ability to exercise adequately; (2) normal resting ECG; and (3) no prior revascularization. Applying this strategy should not sacrifice prognostic accuracy and should result in significant cost savings.