Cardiac single photon emission computed tomography (SPECT) imaging is an established diagnostic and prognostic method for evaluation of suspected and known coronary artery disease. SPECT technology has developed over several decades. Utilization of thallium-201 decreased with the advent of technetium-based perfusion tracers. New cadmium zinc telluride (CZT)-based detectors open a new era of faster imaging and of lower radiation dose to the patient. Appropriate use of the SPECT imaging is regulated by evidence-based guidelines and appropriateness criteria as well as by third-party payers in an effort to curb unsustainable growth of testing seen in recent years. SPECT testing prior to noncardiac surgical procedures is driven by urgency of planned surgery, cardiac risk factors, and perceived risk of surgical procedure. Future of cardiac SPECT imaging will be driven by societal demand for cost effective, accurate, and safe testing, which will improve meaningfully short-term and long-term outcomes.