Ischemia by Treadmill Stress CMR Not Evident by SPECT. Rest and stress images show ischemia by CMR not evident by SPECT in a 56 year-old male with known coronary artery disease was referred for stress testing to evaluate abnormal stress ECG done prior to starting a supervised exercise program. Exercise-induced ischemia is evident by ST depression on electrocardiography (A-rest, F-stress), lateral wall motion abnormality on end-systolic frames from cine CMR (B-rest, G-stress) and lateral perfusion abnormality on first-pass contrast enhanced CMR (C-rest, H-stress). No myocardial infarct scar was seen by LGE CMR (E). SPECT images obtained during the same stress examination suggest normal myocardial perfusion (D-rest, I-stress). Invasive angiography (J) identified high-grade ostial stenosis of a large ramus intermedius coronary artery leading to percutaneous coronary intervention.