Dipyridamole thallium myocardial perfusion imaging is a useful alternative to stress testing in the diagnostic and prognostic assessment of patients with coronary artery disease. The diagnostic use of dipyridamole radionuclide ventriculography is much more controversial, but no long-term prognostic studies have been reported. Imaging results of 159 consecutive patients who were referred for dipyridamole first-pass radionuclide ventriculography were correlated with subsequent cardiac events over a mean follow-up period of 11 months. An abnormal response to dipyridamole infusion (any reduction in wall motion or absolute decrease in global left ventricular ejection fraction of > or = 5 ejection fraction units) was associated with an increased incidence of nonfatal myocardial infarction (4.5% vs 0%, p < 0.05) and cardiac-related death (9% vs 1%, p < 0.001). The sensitivity, specificity, and negative predictive value of dipyridamole first-pass radionuclide ventriculography in predicting future cardiac events were 86%, 71%, and 98%, respectively, with a relative risk of 15 (confidence interval 12.06 to 18.1). In conclusion, dipyridamole first-pass radionuclide ventriculography demonstrated significant prognostic value in a large unselected patient population. This technique may provide a widely applicable and useful alternative to dipyridamole thallium perfusion imaging in the assessment of cardiac risk in patients with coronary artery disease.