The authors' objective was to determine if, in the absence of known coronary artery disease, ST-T changes suggestive of silent ischemia on the admission electrocardiogram (ECG) identify a group of patients at high risk for cardiac event or death. A prospective cohort study was undertaken at the university hospital of a tertiary care center. All patients admitted to the hospital during the 5-month study period were screened. The authors found 54 patients with risk factors but no symptoms of coronary artery disease whose admission ECGs showed silent ischemia (ischemia group), and 71 patients with similar risk of coronary artery disease but without admission ECGs showing silent ischemia (control group). Three-week and 6-month incidences of angina, myocardial infarction, and death among patients in the silent ischemia and control groups were compared. Seven (13%) patients in the silent ischemia group had cardiac events or noncardiac death in the subsequent 3 weeks versus one (1%) noncardiac death in the control group (p < 0.02). At 6 months, eight (15%) patients in the silent ischemia group versus two (3%) in the control group had cardiac events (p = 0.02). It is concluded that among patients with risk factors but no symptoms of coronary artery disease, silent ischemia on the admission ECG is associated with an increased likelihood of short-term death or cardiac event.