The benefit of an invasive strategy in patients with acute coronary syndromes and individuals with symptomatic stable ischemic heart disease is well established. For these indications, coronary angiography defines the extent and severity of obstructive coronary artery disease (CAD), informs our revascularization decisions and is the basis for the excellent outcomes observed for these conditions over the past decades. However, these indications represent only a fraction of the clinical uses of coronary angiography. Cardiac catheterization is frequently used to search for obstructive CAD in other syndromes. These include atypical chest pain or dyspnea in the setting of negative or indeterminate non-invasive tests, Type II non-ST elevation MI and heart failure syndromes. Unlike acute coronary syndromes and symptomatic stable CAD, there is a paucity of data defining the value of coronary angiography in these situations. In fact, most patients undergoing coronary angiograms for these indications are found to have no significant CAD. For example, Patel et al. found that only about a third of patients undergoing elective coronary angiography for a variety of indications had obstructive CAD.