OBJECTIVE--To investigate the short-term effects of atrial, atrioventricular, and ventricular pacing on myocardial oxygen consumption, myocardial blood flow, and cardiac efficiency in patients with coronary artery disease. DESIGN--Prospective study that started at the end of diagnostic coronary angiography in 13 patients and was performed during atrial, atrioventricular, and ventricular pacing for 5 min, in random order, at 20 beats/min more than the heart rate of the patient's positive exercise test. A Baim thermodilution catheter in the coronary sinus was used to measure myocardial blood flow and oxygen consumption and a pacing electrode at the right ventricular apex and a catheter in the pulmonary artery were used to estimate cardiac output. SETTING--Referral cardiology centre. PATIENTS--13 patients with coronary artery disease (mean (SD) age 53(5) years). All the patients had a positive exercise test and most of them (77%) had left anterior descending coronary artery disease. RESULTS--Mean (SD) cardiac output increased by 0.5(1.6) l/min during atrial pacing, increased by 0.1(1) l/min during atrioventricular pacing, and decreased by 0.8(1.2) l/min during ventricular pacing (P = 0.01 v atrial pacing, P = 0.03 v atrioventricular pacing). Diastolic pulmonary pressure increased by 6(4) mm Hg during atrial pacing, by 8.6(4) mm Hg during ventricular pacing (P = 0.02 v atrial pacing), and by 7.5(4.7) mm Hg during atrioventricular pacing. Changes in myocardial oxygen consumption and cardiac efficiency during the different pacing modes were similar. CONCLUSION--Atrial, atrioventricular, and ventricular pacing had similar short-term effects on myocardial oxygen consumption, myocardial blood flow, and cardiac efficiency in patients with coronary artery disease. Ventricular pacing, however, did not increase cardiac output.