To evaluate the usefulness of adenosine triphosphate stress strain imaging for detecting significant coronary artery disease in the left anterior descending coronary artery (LAD), 34 patients underwent coronary flow velocity reserve measurement in the distal LAD and adenosine triphosphate stress strain imaging simultaneously. Time to peak strain (TPS) was measured in the apical septal segment. TPS ratio was obtained as the ratio between TPS at adenosine triphosphate stress and at baseline. TPS ratio in 11 patients with LAD lesions was significantly greater than that in 23 patients without LAD lesions (1.24 ± 0.17 vs 0.92 ± 0.12, respectively, P < .0001). With a cut-off value greater than or equal to 1.1 for the TPS ratio and less than 2.0 for the coronary flow velocity reserve, diagnostic accuracy for the presence of significant LAD lesions were 88% and 82%, respectively. In conclusion, strain imaging can differentiate ischemic and nonischemic myocardium accurately comparable with coronary flow velocity reserve measurement.