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Aims  We analysed whether incorporating electrocardiographic interlead T-wave heterogeneity (TWH) with myocardial perfusion imaging (MPI) during pharmacologic stress improves detection of flow-limiting lesions (FLL). Methods and results  Medical records of all 103 patients at our institution who underwent stress testing with regadenoson (0.4 mg IV bolus) within 3 months of coronary angiography from September 2017 to March 2019 were studied. Cases (N  = 59) had angiographically significant FLL (≥50% of left main or ≥70% of other epicardial coronary arteries ≥2 mm in diameter); controls (N  = 44) were normal or had non-FLL. TWH, i.e. interlead splay of T waves, was assessed from precordial leads V4–6 by second central moment analysis. Maximum TWHV4–6 levels during regadenoson stress were 68% higher in cases than in controls (P  < 0.0001). TWHV4–6 generated areas under the receiver-operating characteristic (ROC) curve of 0.79 in men (P  < 0.0001) and 0.71 in women (P  = 0.007). In men, the ROC-guided 54-µV TWHV4–6 cut-point for FLL produced adjusted odds of 7.3 [95% confidence interval (CI): 1.3–41.5, P  = 0.03], 79% sensitivity, and 78% specificity. In women, the ROC-guided 35-µV TWHV4–6 cut-point produced adjusted odds of 4.5 (95% CI: 1.1–18.9, P  = 0.04), 84% sensitivity, and 52% specificity. Adding TWHV4–6 to MPI determinations reduced false-positive results by 70%, more than doubled true-negative results, and improved adjusted odds ratio to 6.8 (95% CI: 2.2–21.4, P  = 0.001) with specificity of 78% in men and 86% in women. Conclusion  This observational study is the first to demonstrate the benefit of combining TWHV4–6 with MPI to enhance FLL detection during MPI with regadenoson in both men and women. [ABSTRACT FROM AUTHOR]