Dilated cardiomyopathy (DCM) is characterized by ventricular chamber enlargement and systolic dysfunction with normal ventricular wall thickness. More recent studies have shown that the coronary microcirculation may be directly affected in cardiomyopathies. Left ventricular regional myocardial perfusion, wall motion, and metabolism abnormalities are often present in patients with DCM. These data support the possibility that myocardial ischemia may play an important role in the development of DCM and have important prognostic value in patients with DCM. We need to pay attention to the assessment of myocardial blood flow and myocardial ischemia in patients with DCM. Furthermore, anti-ischemic therapy may improve left ventricular function and clinical outcomes in patients with heart failure resulted from DCM.