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The Canadian health care system may provide valuable insights into the future practice of nuclear cardiology in the United States. Rationing of medical care is not legislated by the Canadian health care system, although resource allocation is required of Canadian physicians and hospital administrators. Canadian nuclear cardiologists and physicians are not restricted in the ordering of diagnostic studies, despite the decreased availability in imaging systems and the centralization of equipment and personnel in Canada. Canadian imaging equipment is, in general, used more with less average idle time per unit. Delays in the performance of nonemergent imaging studies are more common in Canadian imaging laboratories. The number of out-of-hospital nuclear medicine laboratories is not increasing, because of government constraints on licensing and the general requirement that only radiologists or certified nuclear medicine physicians can operate these laboratories. A survey of 71 nuclear cardiology laboratories in the United States and Canada reveal that 21% of all cardiac imaging studies are performed for post-myocardial infarction risk stratification in Canada, compared with only 11% in United States laboratories. Rest and reinjection thallium imaging studies are performed more than twice as often in the United States laboratories. Canadian laboratories perform a higher average number of myocardial perfusion (2123 vs 1789) and ventricular function (773 vs 554) studies as compared with their United States counterparts. No other significant differences in clinical usage patterns were identified. A total of 130,000 nuclear cardiologies were performed in Canada in 1993, with less than 5% growth in the number of Canadian studies projected for 1994. Forty-five percent of Canadian perfusion studies are performed with 99mTc-labeled sestamibi frequently using a 2-day protocol (60%) with electrocardiogram gating (30%). Positron emission tomography (PET) can be performed in only six Canadian cities. Canadian PET centers are government funded, located in university teaching hospitals, and principally used for the purpose of research. Stress echocardiography is not widely performed in Canada because of the heavy clinical volume of standard echocardiographic studies at most hospitals, which reduces the time available for stress echocardiography. No separate billing code is available for stress echocardiography studies in Canada. Canadian cardiologists have accepted the value of rest and stress nuclear studies for the management of their patients and have concluded that it is more time efficient to perform clinical duties in lieu of stress echocardiographic studies. In conclusion, the realities of the Canadian health care system are that universal health care is valuable as long as it is consistent high quality medical care, and that the cost of universal coverage must be borne by the taxpayer using the system. The fact that nuclear cardiology has continued to thrive in the Canadian health care system suggests that future health care modifications in the United States will not exert a significant impact on the practice of nuclear cardiology.