OBJECTIVE. This is an analysis of pooled studies for the determination of the test characteristics of stress perfusion cardiac MRI in the diagnosis of flow-limiting obstructive coronary artery disease (CAD) using fractional flow reserve (FFR) at catheter coronary angiography as the reference standard. MATERIALS AND METHODS. Traditionally, planimetric measurement of coronary stenosis at catheter coronary angiography has been considered the reference standard and has been used to verify the diagnostic characteristics of gatekeeper tests. FFR is a physiologic measure of flow limitation and is considered a more authentic reference standard in the diagnosis of CAD. The emergence of a new reference standard questions the true diagnostic accuracy of gatekeeper tests. A systematic literature review was performed for qualifying studies. The DerSimonian-Laird random effects model and a random-effects symmetric summary receiver operating characteristic curve analysis were performed. RESULTS. Twelve studies (761 patients) met the inclusion criteria. Four hundred six stenotic coronary arteries had FFR less than 0.75. Perfusion stress MRI has a sensitivity of 89.1% (95% CI, 84-93%) and specificity of 84.9% (95% CI, 76.6-91.1%) on a patient basis and a sensitivity of 87.7% (95% CI, 84.4-90.6%) and specificity of 88.6% (95% CI, 86.7-90.4%) on a coronary territory basis. CONCLUSION. Stress perfusion MRI remains an accurate test for the detection of flow-limiting stenosis when adjudicated by a physiologic reference standard.