Of all currently available techniques, thallium-201 single-photon emission computed tomography (SPECT) is the most time-tested noninvasive method for the detection of coronary artery disease (CAD). Recent pooled data show an overall sensitivity of 90% and a specificity of 70% for thallium-201 SPECT. Of patients with single-vessel coronary disease, 83% are identified by SPECT. Nearly all patients with double- and triple-vessel coronary disease (93% and 95%, respectively) are also identified. Thallium-201 SPECT imaging is also very effective in diagnosing CAD imaging is also very effective in diagnosing CAD using pharmacologic stress testing. In certain patient populations (e.g., in sedentary patients or those using anti-ischemic medications), pharmacologic stress testing with dipyridamole or adenosine may be a logical alternative to exercise testing. Moreover, many patients have physical disabilities that preclude appropriate exercise testing. Intravenous adenosine is a very potent direct coronary vasodilator, with the advantage of an ultrashort half-life, which eliminates the need to administer an antagonist in the majority of patients. In addition, the dosage of adenosine can be adjusted during the infusion, if necessary. The importance of thallium-201 SPECT during exercise or pharmacologic vasodilation transcends diagnosis, since it also plays an important role in the prognostic evaluation of patients with stable angina or postmyocardial infarction. Risk evaluation can be done with submaximal exercise electrocardiographic testing, but there is evidence that the addition of perfusion scintigraphy enhances the ability to predict future risk.(ABSTRACT TRUNCATED AT 250 WORDS)