Dual-energy x-ray absorptiometric scans of the spine and left hip were performed before stress testing for myocardial ischemia in 629 women and 136 men (mean age 63 years) with chest pain and no previous coronary artery disease. Of the 765 patients, 254 (33%) had osteoporosis, 260 (34%) had osteopenia, and 251 (33%) had normal bone mineral density (BMD). Stress test–induced myocardial ischemia was present in 95 of 254 patients (37%) with osteoporosis, in 81 of 260 patients (31%) with osteopenia, and in 62 of 251 patients (25%) with normal BMD (p = 0.002 comparing osteoporosis with normal BMD and p = 0.007 comparing osteoporosis or osteopenia with normal BMD). Stepwise logistic regression analysis showed that patients with osteoporosis or osteopenia had a 1.7 times higher chance of stress test–induced myocardial ischemia than those with normal BMD after controlling the confounding effects of systemic hypertension, diabetes mellitus, body mass index, and age. In conclusion, patients with chest pain undergoing stress testing have a higher prevalence of stress test–induced myocardial ischemia if they have osteoporosis or osteopenia than if they have normal BMD.