OBJECTIVES: The purpose of this study was to evaluate the prognostic value of community-based myocardial perfusion imaging (MPI) and to assess the incremental value of individual components of 99mTc-sestamibi single photon emission computed tomography (SPECT). BACKGROUND: Although the most rapid growth of MPI has been in community outpatient laboratories, its prognostic value has not been validated in this setting. METHODS: We prospectively followed 1,612 consecutive patients undergoing stress 99mTc-sestamibi SPECT in an outpatient community laboratory who experienced 71 hard events over 24 ± 7 months (0.2% lost to follow-up). RESULTS: Patients whose scans were normal incurred an annualized event rate of 0.4%, compared with 2.3% for those with abnormal scans (p < 0.0001). Subset analysis demonstrated comparable risk stratification for women and men, diabetics, patients with normal resting ECGs, and those referred for pharmacologic and exercise stress. After adjusting for pre-test variables, multivariable Cox regression analysis found the most potent independent components of MPI to be, in order of importance, transient ischemic dilation, extent of reversibility, post-stress ejection fraction, extent and severity of the stress perfusion defect, and the overall test result (normal or abnormal). Each 1% decrement of ejection fraction predicted a 3% increase in risk (p = 0.0009). Post-MPI angiography and revascularization increased commensurate with the extent and severity of MPI result. CONCLUSIONS: The prognostic value of perfusion imaging is portable and transferable to the outpatient community setting, with multiple components of MPI providing incremental prognostic information.