OBJECTIVES: To identify, retrieve, and summarize studies evaluating the cost-effectiveness of selected cardiac imaging tests for the diagnosis of CAD. METHODS: Medline and the National Health Service Economic Evaluation Database (NHSEED) were searched from their inception up to October 2009.  Included studies were those full economic evaluations describing both costs and consequences of a) CT angiography; b) MRI; c) SPECT; and d) stress ECHO in the diagnosis of CAD.  Article selection was performed by independent pairs of researchers.  Target data for extraction included: study first author and year of publication, imaging tests compared, type of economic analysis, reported costs and outcomes, incremental cost-effectiveness ratio (ICER), currency, and patient characteristics (i.e., known or suspected CAD and risk of CAD).   The primary outcome of interest for the present systematic review was the ICER of each imaging test in relation to another test of interest being compared. RESULTS: A total of 12 studies were identified.  Overall, of the selected strategies, stress ECHO was the most compared, followed by SPECT, and CT angiography and MRI.  Results showed that (despite fewer studies) CT angiography was considered cost-effective in all comparisons, however in specific situations such as in the presence of high likelihood or prevalence of CAD or versus stress ECHO and MRI (no comparison was found against SPECT).  Under base-case (average) situations, stress ECHO was reported to be relatively cost-effective, especially in contrast with SPECT and MRI, but not CT angiography.  SPECT follows with few positive cost-effectiveness results, and MRI did not achieve any cost-effectiveness over the other remaining strategies. CONCLUSIONS: Therefore, according to the published economic data from the literature, a cost-effectiveness ranking is proposed for the four analyzed cardiac imaging strategies as follows:  CT angiography (in the presence of high likelihood or prevalence of CAD) > stress ECHO > SPECT > MRI.