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OBJECTIVE To investigate the impact of myocardial perfusion scintigraphy results on the decision for invasive coronary angiography in elderly patients (≥75 years) with suspected coronary artery disease hospitalized in a single tertiary medical center. SUBJECTS AND METHODS In the retrospective study, data of 276 (136 elderly) consecutive hospitalized patients referred to myocardial perfusion imaging were analyzed. The clinical characteristics, myocardial perfusion scintigraphy results, invasive coronary angiography and revascularization rates and in-hospital adverse events were identified by manually reviewing the patients' records. RESULTS Ischemia was found in 40.2% of patients. There was no significant difference in the proportion of ischemia between elderly and younger patients (38.2% vs. 42.1%, P=0.508). Invasive coronary angiography was performed in 64.0% of patients with ischemia and in 6.8% of patients with normal myocardial perfusion imaging (P<0.001). The referral rate for invasive coronary angiography was not different between elderly and younger patients with ischemia (63.5% vs. 64.4%, P=0.848). Ischemia on myocardial perfusion imaging was the most predictive variable for a referral to invasive coronary angiography (odds ratio 31.8, 95% confidence interval 14.6-69.5, P<0.001). There was no significant difference between the younger and elderly patients in revascularization rate and adverse events until discharge (39% vs. 40%, P=0.99 and 7.1% vs. 8.8%, P=0.6, respectively). CONCLUSION Ischemia on myocardial perfusion scintigraphy is a powerful predictor for in-hospital invasive coronary angiography independent of the patient's age. Elderly patients with ischemia received invasive coronary angiography equally as their younger counterparts and have similar rates of adverse events until discharge.