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Individuals with type 2 diabetes are at high risk for cardiovascular events. We evaluated the prognostic value of gated myocardial perfusion single-photon computed tomography (SPECT) for asymptomatic diabetic patients in a Japanese population.Asymptomatic patients (n = 485) aged ≥50 years with either a maximal carotid artery intima-media thickness of ≥1.1 mm, or a urinary albumin ≥30 mg/g creatinine or who had at least two of the following, abdominal obesity, low HDL cholesterol, high triglyceride levels, and hypertension, were enrolled at 50 institutions. The patients were evaluated using gated SPECT with the stress-rest protocol and followed up for 3 years.During the follow-up period, 62 (13%) events occurred, including 5 cardiac deaths and 57 cardiovascular events. Patients with summed stress scores (SSS) of ≥9 had a significantly higher incidence (of either death or cardiovascular events) than those with SSS scores of <9 (23 vs. 12%; P = 0.009). Multivariate Cox regression analysis showed that significant variables were SSS ≥9, a low estimated glomerular filtration rate, and being a current smoker. Univariate Cox regression analysis showed that ticlopidine and insulin use are potent medical modulators of cardiovascular events.The incidences of cardiovascular events and death were significantly high in a select population of type 2 diabetic patients with SPECT abnormalities. A targeted treatment strategy is required for asymptomatic but potentially high-risk patients with type 2 diabetes.