2026 ASNC guideline for stress testing in single-photon emission computed tomography (SPECT) and positron emission tomography (PET) myocardial perfusion imaging.

Stress testing is among the most frequently performed cardiac diagnostic procedures and is widely utilized in both outpatient and inpatient settings performed with and without myocardial perfusion imaging (MPI). Since the 2016 American Society of Nuclear Cardiology (ASNC) guideline, clinical experience with cardiac stress testing has continued to expand and evolve necessitating updates to the previous guidelines. This guideline presents updated practice standards for cardiac stress testing intended to support safe and effective testing across a range of clinical environments, while allowing for individualized risk assessment and protocol adaptation based on patient characteristics, special populations, and site-specific logistics. The current guideline offers practical beginning-to-end guidance on the performance of cardiac stress testing, encompassing patient selection and preparation, stress modalities and protocols, safety considerations, and result interpretation and reporting. The utilization of single photon emission computed tomography (SPECT) and positron emission tomography (PET) in conjunction with stress testing are addressed for stress protocols for each available stressor. This revised guideline is intended for a broad, multidisciplinary audience involved in the performance, interpretation, and oversight of cardiac stress testing. ASNC has developed this updated guideline to recognize the evolution of diagnostic imaging that has taken place since the last iteration of the guideline. These updates are intended to support optimal test selection, standardized patient preparation, and individualized, patient-centric practice of nuclear stress testing in diverse clinical scenarios. Utilizing this guideline, clinicians will optimize diagnostic accuracy, maintain patient safety, and at the same time maximize clinical impact.