Background-Although high exercise tolerance is associated with an excellent prognosis, the significance of abnormal myocardial perfusion imaging (MPI) in patients with high exercise tolerance has not been established. This study retrospectively compares the utility of MPI and exercise ECG (EECG) in these patients. Methods and Results-Of 388 consecutive patients who underwent exercise MPI and reached at least Bruce stage IV, 157 (40.5%) had abnormal results and 231 (59.5%) had normal results.

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... low-up was performed at 18Ϯ2.7 months. Adverse events, including revascularization, myocardial infarction, and cardiac death, occurred in 40 patients. Nineteen patients had revascularization related to the MPI results or the patient's condition at the time of MPI and were not included in further analysis. Seventeen patients (12.2%) with abnormal MPI and 4 (1.7%) with normal MPI had adverse cardiac events (PϽ0.001). Cox proportional-hazards regression analysis showed that MPI was an excellent predictor of cardiac events (global 2 ϭ13.2; PϽ0.001; relative riskϭ8; 95% CIϭ3 to 23) but EECG had no predictive power (global 2 ϭ0.05; Pϭ0.8; relative riskϭ1; 95% CIϭ0.4 to 3.0). The addition of Duke's treadmill score risk categories did not improve the predictive power of EECG (global 2 ϭ0.17). The predictive power of the combination of EECG (including Duke score categories) and MPI was no better than that of MPI alone (global 2 ϭ13.5). Conclusions-Unlike EECG, MPI is an excellent prognostic indicator for adverse cardiac events in patients with known or suspected CAD and high exercise tolerance. (Circulation. 1999;99:867-872.)