The prognostic value of stress thallium-201 myocardial perfusion imaging has not been defined in an elderly (at or above 70 years) population. To this end, we studied 468 consecutive elderly patients undergoing either Bruce protocol exercise stress (n equals 120) or intravenous dipyridamole stress (n equals 348) with quantitative planar thallium-201 imaging. These patients were followed for at least 2 years after testing to determine their rates of cardiac events (cardiac death, myocardial infarction, coronary revascularization). There were no stress-related complications in either subgroup. A 10% cardiac event rate (6 deaths and 6 myocardial infarctions) was observed in the exercise subgroup. Survival without cardiac events was associated with greater exercise duration (5.6Â+/-2.4 vs 3.1Â+/-2.4 min; P is less than 0.001) and peak exercise heart rate (131Â+/-18 vs 120Â+/-19 bpm; P is less than 0.05). Multivariate analysis identified the combination of peak exercise at or below Stage 1 and thallium-201 perfusion defects as significant predictors of cardiac events (relative risk equals 5.3 at 1 year). Sixty-four percent of elderly patients were successfully stratified into very low and high risk subgroups, with annual cardiac event rates of less than 1% and greater than 15%, respectively. The cardiac event rate in dipyridamole stress patients was 22% (24 myocardial infarction, 52 death, 42 revascularization). The cardiac event rate was significantly lower (5%) in 150 patients with a normal dipyridamole thallium-201 study (P is less than 0.001). Clinical univariate predictors of cardiac events were previous myocardial infarction, congestive heart failure symptoms, hypercholesterolemia and diabetes (all P equals 0.05). A fixed, reversible, or combined thallium defect pattern was correlated with cardiac death or myocardial infarction (P is less than 0.05). Multivariate analysis demonstrated that the presence of an abnormal dipyridamole thallium study was the single-best predictor of cardiac events (relative risk equals 7.2; P is less than 0.01) We conclude that exercise and dipyridamole thallium-201 myocardial imaging are powerful independent noninvasive techniques for prognostication in the elderly patient population, a group with the potential for advanced coronary artery disease and a high risk of cardiac events.