Patients with mitral valve prolapse (MVP) frequently experience chest pain which may, expecially in older subjects and males, be difficult to differentiate from angina pectoris. Electrocardiographic (ECG) changes, ventricular arrhythmias, metabolic abnormalities and rare reports of myocardial infarction and sudden death further suggest the presence of an ischemic process in these patients. The recognition of accompanying coronary artery disease (CAD) and exclusion of other causes of ischemia, therefore, may be important in determining the prognosis and appropriate therapy for such patients.We performed stress ECGs and perfusion scintigrams in 25 patients with confirmed MVP who underwent cardiac catheterization or evaluation of chest pain. Stress ECGs were not helpful in iagnosing associated CAD, primarily because of a high incidence 53%, 10/19) of false positive tests, and had only a 48% overall accuracy. cintigraphy was more accurate (P < 0.001), correctly classifying all patients. Scintigraphy was uniformly negative in patients with normal coronary arteriograms, suggesting that ischemia, if present as the cause of chest pain and ECG changes, must be either very localized or generalized.