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There are currently insufficient data to indicate a role for stress myocardial perfusion imaging as a prognostic tool in hypertensive patients.To assess the incremental value of stress myocardial perfusion imaging for the prediction of cardiac death in hypertensive patients relative to clinical data.We studied 601 hypertensive patients (aged 59 ± 10 years, 387 men) who underwent exercise bicycle or dobutamine (up to 40 μg/kg per min) stress technetium-99m tetrofosmin single photon emission computed tomography (SPECT) for evaluation of coronary artery disease.Cardiac death during follow-up.An abnormal scan (reversible or fixed perfusion abnormalities) was detected in 293 (49%) patients (134 had reversible abnormalities). During a mean follow-up period of 3.1 ± 1.3 years, 109 (18%) patients died; of whom, 42 patients (39%) died due to cardiac causes. Independent predictors of cardiac death were age [hazard ratio = 1.04, 95% confidence interval (CI) 1.01–1.08], history of previous myocardial infarction (hazard ratio = 2, CI 1.1–3.7), stress rate–pressure product (hazard ratio = 0.94, CI 0.87–0.98) and abnormal scan (hazard ratio = 4.7 CI 1.9–11.4). Both reversible and fixed abnormalities were predictive of death. The annual cardiac death rate was 5.3% in patients with an abnormal and 0.5% in patients with a normal perfusion scan.Stress technetium-99m tetrofosmin myocardial perfusion imaging provides prognostic information incremental to clinical data for the prediction of cardiac death in hypertensive patients with known or suspected coronary artery disease.