OBJECTIVE To establish, in our area, the clinical significance of a normal exercise myocardial perfusion study, in patients with an ischemic response of the exercise test. METHODS A retrospective study was carried out in our Service for the last four years. We studied 45 patients (41 women and 4 men) with an ischemic response of the exercise test and normal myocardial perfusion SPECT, during a mean follow-up of 13,2 months. We considered the final clinical diagnosis according to clinical evolution, therapy outcome and coronary angiography results. RESULTS The presence of positive exercise test and normal SPECT was predominant in women (93.3%). In 35 patients (77.8%), the final diagnosis was chest pain of probable non-coronary origin (not secondary to coronary artery disease): 18 patients were diagnosed of hypertensive cardiomyopathy, 3 of valvulopathy, 2 of vasospastic angina, 1 of hypertrophic obstructive cardiomyopathy, 1 of microvascular angina, 1 of angina due to arrhythmia, and 9 patients diagnosed of atypical chest pain due to functional or non-cardiac origin. In 10 patients (22.2%), the final diagnosis was chest pain of probable coronary origin. We did not observe any major cardiac events (cardiac death and nonfatal myocardial infarction) during the follow-up period. CONCLUSIONS Patients with chest pain, positive exercise test and normal SPECT have an excellent prognosis within an intermediate follow-up period. 77.8% of patients were diagnosed of chest pain of non-coronary origin. The most common cause of non-coronary chest pain was hypertensive cardiomyopathy (51.4%), followed by functional or non-cardiac chest pain (28.6%).