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Objectives: To determine the prognostic value of myocardial necrosis and ischemia analised using dipyridamole stress cardiac magnetic resonance (CMR) for predicting major events in patients with systolic disfunction and with diagnosed or suspected ischemic cardiomyopathy.Methods: We prospectively included 274 patients with depressed ejection fraction (EF) (<50%, median 38±9%) and known or suspected ischemic cardiomyopathy referred for study using dipyridamole stress CMR. We quantified the extent (number of segments, s) of: ischemia (perfusion deficit in stress first-pass perfusion imaging), severe ischemia (perfusion deficit plus dipyridamole-induced wall motion abnormalities) and necrosis (late enhancement in >50% of wall thickness in late enhancement imaging). Abnormal CMR indexes were regarded if >1 s was altered.Results: During a median follow up of 329 days 20 deaths and 19 myocardial infarctions were detected. Overall 28 first major events (10%, death or myocardial infarction) were registered. Ischemia was observed in 170 patients (62%), severe ischemia in 22 (8%) and necrosis in 184 (67%). More major events were detected in patients with ischemia (13% vs.. 5%, p = 0.02) and a tendency in those with necrosis (12% vs. 7%, p = 0.1). The presence of severe ischemia was strongly associated with major events (45% vs. 7%, p <0.001). After adjustment for baseline characteristics and all CMR indexes, the predictors of major events (hazard ratio [95% confidence intervals ] were end-systolic volume index (1.01 [1-1.02] per ml/m2, p = 0.001), extent of necrosis (1.1 [1.01-1.2] per s, p = 0.02) and extent of severe ischemia (2.1 [1.7-2.7 ] per s, p <0.001).Conclusions: In patients with known or suspected ischemic cardiomyopathy, the presence of severe ischemia is the most powerful prognostic index. A simultaneous study of viability and ischemia is recommended for risk stratification. CMR represents an ideal tool for this purpose.