Diagnosis of left bundle branch block (LBBB) with concomitant coronary artery disease (CAD) alters the prognosis and the therapeutic management. All common non-invasive stress tests have a limited performance to identify CAD in patients with LBBB. Thus invasive coronary angiography is often needed to confirm or defer obstructive CAD. We propose a new diagnostic algorithm in evaluation of symptomatic and asymptomatic patients with LBBB.