ABSTRACT Background: Myocardial ischemia (IHD) has been shown to be the leading cause of death in patients with transient ischemic attacks (TIAs), causing more deaths than stroke. Coronary artery disease (CAD) is a frequent cause of death among stroke survivors. Recently appeared guidelines encourage healthcare professionals to optimize coronary risk evaluation in patients with transient ischemic attack (TIA) and ischemic stroke to establish appropriate strategies to prevent incident coronary artery disease. Objective: To detect the silent myocardial ischemia among patients presented with transient ischemic attacks. Patients and methods: This study was conducted on 50 asymptomatic patients with transient cerebral ischemic attack at Al-Azhar University Cardiology Department, during period from October 2019 to October 2021. All patients underwent thorough history taking, clinical examination, electrocardiogram, 2D echocardiography and SPECT scan Myocardial perfusion imaging (MPI). Results: Echocardiographic data showed that mean ejection fraction of the studied group was 64.82±6.24, 24% of patients had Resting segmental wall motion abnormalities (RSWMA), 24% had dilated left atrium and 72% had diastolic dysfunction. There were statistically significant differences between positive and negative myocardial perfusion imaging (MPI) patients regarding risk factors including diabetes mellitus, dyslipidemia and smoking. Also, there were statistically significant differences between positive and negative myocardial perfusion imaging patients regarding prominent a wave, neurologic symptoms, echocardiographic data (except left ventricular posterior wall end-diastolic dimension (PWEDd) and Interventricular septum diastolic dimension (IVSDd)). Regression analysis showed that age, diabetes mellitus, dyslipidemia, smoking, fractional shortening, resting wall motion abnormalities (RWMA) score index, left atrial (LA) dilation, diastolic dysfunction and left ventricular end-diastolic diameter (LVEDD) were independent predictors of positive single-photon emission computed tomography (SPECT) scan. Conclusion: Patients who have TIA with no known coronary artery disease have approximately twice the risk for a subsequent myocardial ischemia compared to the general population. This risk accumulated linearly over time for many years after the transient ischemic attack.