The exercise ECG: still a useful exercise?

What is wrong with traditional ST-segment criteria during the exercise ECG? As we all know from daily practice, poor sensitivity of the exercise ECG for the detection of myocardial ischaemia is a major diagnostic weakness and a critical limitation of the exercise procedure. In standard meta-analyses, 1.0 mm (0.1 mV) of horizontal or downward-sloping ST depression has a sensitivity of only 68% for the detection of coronary artery disease (CAD), and this figure is even lower for women. This might explain our increasing reliance on noninvasive imaging modalities such as nuclear imaging (SPECT), magnetic resonance imaging (MRI), and computed tomography angiography (CTA), all of which show sensitivities between 80 and 90% for detecting CAD. As a result, there is a tendency to consider the exercise ECG as a poor man’s procedure to demonstrate myocardial ischaemia due to CAD. Is this the right consideration?