All components of the metabolic syndrome increases the risk of cardiovascular diseases, and diabetes is considered to be a particularly strong negative prognostic factor. Patients with diabetes often deny typical angina symptoms, complaining only nonspecific shortness of breath, excessive sweating, fatigue, exhaustion. At the same time its presence is associated with a significant underestimation of coronary artery disease, later diagnosis of cardiac ischemia, suboptimal drug therapy and less frequent coronary interventions. The authors present a case of a patient with metabolic syndrome (angina symptoms denier), diagnosed due to discrete electrocardiographic abnormalities. A sequence of noninvasive imaging (nuclear exercise stress test, echocardiography with speckle tracking imaging) enabled the identification and assessment of the effect of treatment of advanced coronary artery disease. Especially valuable was the observation of delayed ST segment elevation during the recovery phase of the nuclear exercise stress test, which is a very rare phenomenon, suggesting a significant narrowing of the epicardial vessel. In presented case, the diagnosis of coronary artery disease was established with use of modern imaging techniques, which guarantee the safety of the patient. The use of these highly reliable diagnostic methods enabled the detection of critical stenosis of the right coronary artery that in the near future could result with acute coronary syndrome, as the first clinical manifestation of coronary artery disease. In case of any diagnostic doubts, especially in asymptomatic patients with high cardiovascular risk, the personalized approach and use of all available imaging tools should be recommended.