PURPOSE: To determine the usefulness of first-pass contrast-enhanced magnetic resonance (MR) perfusion imaging for assessment of myocardial ischemia in patients with angiographic three-vessel coronary artery disease. MATERIALS AND METHODS: First-pass contrast-enhanced MR images of the entire left ventricle were acquired in 41 patients at rest and during adenosine-induced stress by using saturation-recovery SSFP (sense balanced-FFE). Coronary angiography was performed in all patients, and stress-rest single photon emission computed tomography (SPECT) with thallium was performed within 2 weeks. Image analyses were performed to compare the diagnostic accuracies of first-pass contrast-enhanced stress MR imaging (stress MR) and stress SPECT, with coronary angiography as the reference standard. RESULTS: In patients with angiographic three-vessel CAD, stress MR identified significantly more abnormal segments (9.31 짹 3.76 vs 5.78 짹 2.75, P < 0.001). Stress MR detected balanced three vessel disease in 7 patients by demonstrating subendocardial perfusion defect of whole vascular territory. Stress SPECT showed normal perfusion and washout in one patient, but stress MRI exactly showed ischemia of whole vascular territory. CONCLUSION: In patients with angiographic three-vessel coronary artery disease, stress MR imaging can identify of myocardial ischemia more closely with coronary angiography results than does stress SPECT.