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Previous studies revealed a relatively high prevalence of electrocardiographic findings indicative for myocardial ischemia in asymptomatic athletes undergoing pre-participation screening. Myocardial perfusion scintigraphy is generally considered a valuable diagnostic and prognostic modality and often used for further diagnostic evaluation in these subjects. However, data on the diagnostic accuracy of myocardial perfusion scintigraphy in athletes are scarce.The main purpose of this study was to investigate the positive predictive value of myocardial perfusion scintigraphy for detection of coronary artery disease in asymptomatic athletes with abnormal exercise testing results during pre-participation screening. The secondary aim was to evaluate the prognostic value of myocardial perfusion scintigraphy.Electronic charts of asymptomatic athletes who underwent myocardial perfusion scintigraphy following an abnormal exercise testing were retrospectively reviewed. Myocardial perfusion scintigraphy and exercise testing studies were revised. Athlete characteristics and cardiovascular risk factors were evaluated.One hundred and forty-three athletes were included. 29 athletes (20%) showed concordant abnormal exercise testing and myocardial perfusion scintigraphy results. Coronary imaging was performed in 20 of these 29 athletes. Four athletes showed significant coronary artery disease (positive predictive value = 20%). The positive predictive value increased to 33% when athletes were selected who should have undergone exercise testing according to the guideline recommendations. During a mean follow-up interval of 4.7 ± 2.2 years, eight cardiac events occurred. Athletes with an abnormal myocardial perfusion scintigraphy result had a fourfold increased risk at a future cardiac event (2.9%/year versus 0.75%/year, p = 0.031).The positive predictive value of myocardial perfusion scintigraphy for the detection of significant coronary artery disease in asymptomatic athletes with a positive exercise testing result is low, even in a selection of athletes with a relatively high cardiovascular risk. Although an abnormal myocardial perfusion scintigraphy result was associated with a fourfold higher annual event rate, the absolute annual event rate in this group was still low. Efforts should be made to develop better diagnostic strategies to evaluate asymptomatic athletes with abnormal exercise testing results during pre-participation screening.