Background: Patients with end stage renal failure (ESRF) have an increased risk of premature cardiovascular disease which is a leading cause of death. Circulating biomarkers play a major role in the early detection of cardiovascular disease in those patients. N-terminal-pro-BNP is a cardiac biomarker which is frequently elevated in patients with CKD. However, because NT-pro BNP clearance may depend on renal function, the significance of an elevated level in patients with chronic kidney disease (CKD) without cardiac symptoms is uncertain. The use of myocardial perfusion imaging (MPI) for patients with renal disease may be useful for diagnosing CAD and providing powerful information about the risk of future cardiac events. This study aimed to explore the prevalence of different cardiac events in CKD patients according to the grade of kidney damage , to explore the degree of elevation of N-terminal-pro-BNP in asymptomatic cardiac patients with varying degree of CKD; to clarify the relationship between the elevation of this biomarker and the occurrence of cardiac events in CKD patients and to study the usefulness of MPI by Single photon computed tomography (SPECT) as a diagnostic a diagnostic tool for cardiac events in patients with varying degree of CKD regardless hemodialysis. Subjects and methods: This case –control observational retrospective study was conducted on 40 CRF patients with varying degree of CKD, 13 –85 years old (mean age 47±17.3 years), recruited from the renal and dialysis unit, department of Internal Medicine, Assuit University Hospitals, Egypt from 2009-2010.In addition to 40 age and sex matched healthy persons as a control group .The patients were classified into two groups: 20 non-dialysis CRF patients on conservative treatment and 20 patients on hemodialysis. All are subjected to thorough history taking, full clinical examination, and anthropometric measurements. We measured serum levels of CRP and N-terminal-pro-BNP in all subjects. MPI by SPECT was done in some selected cases. Results: NT-pro BNP levels were elevated in all patients with significant higher levels in ESRD patients on HD. Whereas, the levels of NT-pro BNP were more significantly elevated with Hypertension, Anemia, Hypoalbuminemia, advanced LVH and LV dysfunction , their levels were not significantly elevated with gender ,advanced age and increased BMI. In CKD patients with varying degree, highly significant positive correlations between NT-pro BNP levels and LV mass and LV mass index were found; however, there was a highly significant negative correlation between their levels and systolic function tested by TTE. CRP levels were elevated in all studied patients with significant higher levels in ESRD patients on HD. perfusion defects have been seen in majority of CKD patients. Half of them showed a moderate degree hypoperfusion while one-fourth of cases had severer pattern. Multiple vessel affection was a characteristic feature. Significantly higher NT-pro BNP levels were seen in patients had moderate and severe degrees of hypoperfusion. A highly significant negative correlation between systolic function (EF) evaluated by MPI and NT-pro BNP levels. Majority of Patients with grade II-III CKD under SPECT had mild to moderate degrees of hypoperfusion with good systolic function and a characteristic two vessel affection. However, half of Patients with grade IV-V CKD under SPECT had a severe degree of hypoperfusion with an impaired systolic function .Two and multi-vessel affections are characteristic in Patients with grade IV-V CKD in equal percent. Nevertheless, there was a significant positive correlation between EF evaluated by MPI and TTE. Conclusion: In essence, MPI SPECT provides effective risk stratification across the entire spectrum of renal function in CKD patients. Moderate to severe degrees of hypoperfusion with multiple vessel affections were characteristic patterns especially in CKD patients on dialysis. N-terminal-pro-BNP level elevation in asymptomatic patients with CKD reflects underlying ischemic heart disease and hypertrophy independent of renal function in a population with anticipated high cardiac morbidity. Thus, N-terminal-pro-BNP can be a good parameter for predicting the severity of coronary vessels involvement and in evaluating cardiac risk in patients with ESRD especially those on HD besides other diagnostic tools. Severer degrees of hypoperfusion were associated with Higher NT-pro BNP levels. Moreover, there wa highly significant negative correlation between systolic function evaluated by MPI and NT-pro BNP levels.