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Abstract: Objective: The primary aim of the present study was to calculate the actual costs of four diagnostic tests for the detection of coronary artery disease in the Netherlands using a microcosting methodology. As a secondary objective, the cost effectiveness of eight diagnostic strategies was examined, using microcosting and reimbursement fees subsequently as the cost estimate. Design: A multicenter, retrospective cost analysis from a hospital perspective. Setting: The study was conducted in three general hospitals in the Netherlands for 2006. Interventions: Exercise electrocardiography (exECG), stress echocardiography (sECHO), single-photon emission computed tomography (SPECT) and coronary angiography (CA). Results: The actual costs of exECG, sECHO, SPECT and CA were €33, 216, 614 and 1300 respectively. For all diagnostic tests, labour and indirect cost components (overheads and capital) together accounted for over 75% of the total costs. Consumables played a relatively important role in SPECT (14%). Hotel and nutrition were only applicable to SPECT and CA. Diagnostic services were solely performed for CA, but their costs were negligible (2%). Using microcosting estimates, exECG–sECHO–SPECT–CA was the most and CA the least cost effective strategy (€397 and 1302 per accurately diagnosed patient). Using reimbursement fees, exECG–sECHO–CA was most and SPECT–CA least cost effective (€147 and 567 per accurately diagnosed patient). Conclusions: The use of microcosting estimates instead of reimbursement fees led to different conclusions regarding the relative cost effectiveness of alternative strategies. [Copyright &y& Elsevier]