Coronary artery disease (CAD) contributes to high mortality rate in end-stage renal disease (ESRD) patients. Single photon emission computed tomography (SPECT) using ²⁰¹Thallium (TI) or ^99mTechnetium-labeled tracers has been used to detect CAD, but they require physical or pharmacological stress loading. Resting SPECT using an iodinated fatty acid analogue, 15-(p-[I-123]-iodophenyl)-3-(R, S) methylpentadecanoic acid (¹²³I-BMIPP), can assess fatty acid metabolism in the myocardium. We investigated the ability of ¹²³I-BMIPP SPECT to detect CAD in hemodialysis patients, and compared with ²⁰¹TI SPECT. We prospectively enrolled 130 ESRD patients undergoing hemodialysis with a mean duration of 88.6 months (male/female: 77/53, mean age: 63.8 years). Dual SPECT using ¹²³I-BMIPP and ²⁰¹TI was performed, which was followed by coronary angiography (CAG). SPECT imaging was evaluated and graded in 17 segments using a five-point scale (0=normal, 4=absence). Final assessment was based on the summed score. On CAG, 71.5% of patients (93/130) showed a significant coronary stenosis (≥75%), and 5 patients showed coronary spasm without coronary stenosis. When a BMIPP summed score of 6 or more was defined as abnormal. Its sensitivity, specificity, and accuracy for detecting CAD by BMIPP SPECT were 98.0, 65.6, and 90.0%, respectively. In contrast, these parameters for detecting CAD by TI SPECT were 84.7, 46.9, and 75.0%, respectively, when a TI summed score of 1 or more was defined as abnormal. In receiver operating characteristic (ROC) analysis, the area under the curve indicating the ability to diagnose CAD was 0.895 in BMIPP and 0.727 in TI SPECT. Resting BMIPP SPECT imaging is superior to TI SPECT for detecting coronary lesions, and provides safe screening for CAD among maintenance hemodialysis patients.