OBJECTIVE Myocardial perfusion is routinely measured by SPECT--this technique has a rather low spatial resolution but covers the whole myocardium and is equipped with efficient image analysis software. Cardiac MRI has higher spatial resolution than SPECT and excellent sequences for myocardial function and viability detection but the lack of easy-to-use methods of acquisition and post-processing of perfusion images prevents this method from being used for perfusion evaluation in clinical practice. The aim of the study was to explore whether the 3-D co-registration of "cine" MRI (cine MRI), delayed enhancement MRI (DE MRI) and gated SPECT (GSPECT) images might be used for differentiating all reversible and irreversible effects of ischemia in anatomically matched myocardial regions. METHODS We analyzed 685 segments of the heart (6 segments in each short axis slice)-obtained as a result of MRI and GSPECT studies performed in 18 patients. In each segment, myocardial function, perfusion and viability were analyzed. Myocardial wall function was evaluated using the matched images of diastolic and systolic phases of cine MRI. Perfusion as MIBI uptake per volume (MIV) (counts/mm3) in each myocardial segment was evaluated by co-registration of diastolic phases of cine MRI and GSPECT. Transmural extent of infarction was determined by co-registration of DE MRI and diastolic phase of cine MRI. RESULTS We have found a close correlation between regional perfusion and function at rest in matched MRI and SPECT images: dysfunctional segments had significantly less MIV (MIV = 4.63 SD 1.58) than normal segments (MIV = 8.86 SD 2.77) (p < .05). There was no significant difference in MIV between viable and non-viable dysfunctional segments defined by DE MR due to a small number of nonviable segments in our study (18/685). CONCLUSIONS Matching rest perfusion and function in anatomically co-registered myocardial segments in our study confirms that 3-D image co-registration of cine MRI, DE MRI and gated SPECT could be a precise method of integrated visualization of perfusion, function and viability helping in differentiating all forms of reversible and irreversible effects of myocardial ischemia.