['In chronic total occlusion (CTO), the evidence for revascularization is less robust than for stable angina. A medical therapy strategy is common and often based on distal collateralization, regardless of the presence of ischemia.', 'The aim of this study was to examine the correlation between distal collateralization, myocardial perfusion imaging (MPI), and hard cardiac events (HCE) in CTO.', 'Retrospective analysis of consecutive patients undergoing coronary angiography revealed 21 non-revascularized patients with CTO and MPI, over a 24-month period. Blinded review of patient charts, MPI, and angiography was undertaken. HCE of death, myocardial infarct, and unstable angina were assessed. Mean follow up was 23 months.', 'Summed difference scores were calculated on a 17-segment model and collaterals graded on the Rentrop scale. 43% of patients had HCE, and 62% had collaterals. Ischemia on MPI accurately predicted HCE in CTO (60% vs 0%, P = .01). Distal collateralization failed to predict freedom from ischemia on MPI (31% vs 25%, P = .53) or HCE (31% vs 62%, P = .15).'] Is myocardial perfusion imaging ( MPI ) superior to the demonstration of distal collaterals in predicting cardiac events in chronic total occlusion ( CTO )?