Silent myocardial ischemia is highly prevalent in patients with end-stage renal disease (ESRD), and is associated with poor cardiovascular outcomes. However, the criteria for coronary artery disease screening remain unclear in asymptomatic patients. The goal of this study was to evaluate whether baseline echocardiographic parameters can predict myocardial ischemia in asymptomatic patients with ESRD. We investigated 259 high-risk asymptomatic patients with ESRD who underwent both echocardiography and myocardial perfusion single-photon emission computed tomography at the initiation of dialysis. We defined the presence of myocardial ischemia as a reversible or fixed perfusion defect. Silent myocardial ischemia was found in 99 (38.2 %) high-risk asymptomatic patients with ESRD at the initiation of dialysis. In patients with myocardial ischemia, left ventricular (LV) end systolic volume index, LV mass index, left atrial volume index (LAVI), and the ratio of early mitral inflow velocity to peak mitral annulus velocity were significantly higher, and LV ejection fraction was significantly lower, than those without myocardial ischemia. Multivariate analysis showed that LAVI, LV ejection fraction, and regional wall motion abnormalities were independently associated with the presence of silent myocardial ischemia. Severe (LA) enlargement was independently associated with the presence of silent myocardial ischemia (odds ratio 1.97; 95 % confidence interval 1.08-3.57; p = 0.026). LA enlargement is a potential marker for identifying patients with ESRD at high risk of silent myocardial ischemia.