Stress echocardiography combines two-dimensional echocardiography with a physical, pharmacological, or less commonly, electrical stress with atrial pacing.  Stress-induced ischemia generates new or worsening wall motion abnormalities in the segment supplied by the stenosed coronary artery. Stress echocardiography plays an important role in identifying these wall motion abnormalities in the assessment of ischemic heart disease, and also plays a vital role in the evaluation of systolic or diastolic heart failure, valvular pathologies, nonischemic cardiomyopathy, pulmonary hypertension, and congenital heart disease. 
Anatomy involves studying the various wall motion abnormalities and understanding the vascular territories associated with various segments. The segments are studied in six views: the parasternal long axis, the parasternal short axis at the levels of the mitral valve, papillary muscles, and apex, apical four chambers, apical two chambers. The scoring system is based on if the wall motion is normal, hypokinetic, akinetic, or dyskinetic. Based on the wall motion, a score of 1 to 4 is assigned. The American Society of Echocardiography uses a 17-segment model for wall motion abnormalities. 
Parasternal long axis (PLAX) view
Segments seen in parasternal long-axis view:
Apical four chambers (A4C) view
Segments seen in apical four-chamber view:
Apical two chambers (A2C) view
Segments saw in apical two-chamber view:
Parasternal short-axis (SAX) view
Segments seen in parasternal short-axis view at the papillary muscle level:
Specific contraindications to dipyridamole (or adenosine) and dobutamine stress echocardiography include severe conduction abnormalities (high-degree AV block without pacemaker), active bronchospasm, Sick sinus syndrome without a pacemaker, systolic blood pressure less than 90 mmHg, and tachyarrhythmias such as atrial fibrillation.
Technical equipment for stress echocardiography includes:
Stress echocardiography equipment takes into consideration M-mode, two-dimensional, color, and spectral (both flow and tissue) Doppler imaging for evaluation of ischemic heart disease.
Contrast agents are used as indicated for patients in whom at least two endocardial wall territories are not well visualized.
Tissue harmonic imaging is indicated in stress echocardiography. It improves resolution, reduces artifacts, improves signal-to-noise ratio, greater depth of penetration and improves myocardial signals. Tissue harmonic imaging increases the sensitivity of stress echocardiography as it improves endocardial delineation due to enhanced resolution.
Intravenous contrast agents in combination with harmonic imaging increase the accuracy of the procedure. Increased number of wall segment motion abnormalities can be studied when contrast agents are used.
Stress testing methods:
Exercise stress testing: This is indicated in patients who can exercise. Either treadmill or bicycle can be used for exercise.
Imaging obtained at resting and stress phase are compared for interpretation of left ventricular (LV) size, shape, and function. A normal response during stress involves LV size becoming smaller compared to rest, while the shape is maintained, and there is increased endocardial excursion along with systolic wall thickening.
In a patient with multiple vessel diseases, exercise echocardiography demonstrates a dilated LV cavity with changes in the shape and reduction of systolic wall thickening of the septum, anterior, and inferior walls. Prolonged systolic wall thickening may also indicate severe coronary artery disease.
The coronary arteriographic cut off of luminal diameter stenosis at which wall thickening abnormalities occur is 54% for exercise, 58% for dobutamine, and 60% for dipyridamole. The sensitivities for the detection of coronary artery disease (CAD) are 85%, 80%, and 78%, with specificities of 77%, 86%, and 91% for exercise, dobutamine, and dipyridamole stress results.  However, diagnostic accuracy varies according to the pretest likelihood of CAD in the patient tested.
Dobutamine stress echocardiography: The most common cardiovascular side effects associated with dobutamine are angina, hypotension, and cardiac arrhythmias.  Atrial fibrillation and nonsustained ventricular arrhythmias occur in about 3% of patients. ,  Sustained ventricular tachycardia is not common. Dobutamine can also induce left ventricular mid-cavity and outflow tract obstruction. Frequent premature atrial or ventricular contractions occur in about 10%. 
Vasodilator stress echocardiography: Major adverse reactions include myocardial infarction, asystole, and ventricular tachycardia.  Hypotension and bradycardia may occur but can be treated with aminophylline.
Pacing stress echocardiography: Wenckebach's second-degree heart block may occur, requiring atropine administration. 
In terms of clinical significance and diagnostic accuracy, stress echocardiography has an advantage in terms of specificity over standard exercise electrocardiography. When compared to nuclear perfusion imaging studies, stress echocardiography has similar accuracy, with a moderate sensitivity gap that is well balanced by a higher specificity. Both dipyridamole and dobutamine have overall good tolerance and feasibility. The choice of one test over the other depends on patients' clinical characteristics and the physician's preference. Diagnostic accuracy can significantly be affected by antianginal medical therapy, particularly beta-blocking agents, and therefore, it is recommended to withhold medical therapy at the time of testing to avoid a false-negative result.
Healthcare workers, including nurse practitioners, will frequently encounter patients with heart disease. One of the ways to investigate these patients is with stress echocardiography. Stress echocardiography is the combination of two-dimensional echocardiography with a physical, pharmacological, or less commonly, electrical stress with atrial pacing. Stress-induced ischemia generates new or worsening wall motion abnormalities in the segment supplied by the stenosed coronary artery. Stress echocardiography plays an important role in identifying these wall motion abnormalities in the assessment of ischemic heart disease, and also plays a vital role in the evaluation of systolic or diastolic heart failure, valvular pathologies, nonischemic cardiomyopathy, pulmonary hypertension, and congenital heart disease.
|||Picano E,Pasanisi E,Venneri L,Agrusta M,Mottola G,Sicari R, Stress echocardiography. Current pharmaceutical design. 2005 [PubMed PMID: 16026284]|
|||Gillam LD,Marcoff L, Stress Echocardiography. Circulation. Cardiovascular imaging. 2019 Jun [PubMed PMID: 31203671]|
|||Sicari R,Cortigiani L, The clinical use of stress echocardiography in ischemic heart disease. Cardiovascular ultrasound. 2017 Mar 21; [PubMed PMID: 28327159]|
|||Pellikka PA,Nagueh SF,Elhendy AA,Kuehl CA,Sawada SG, American Society of Echocardiography recommendations for performance, interpretation, and application of stress echocardiography. Journal of the American Society of Echocardiography : official publication of the American Society of Echocardiography. 2007 Sep; [PubMed PMID: 17765820]|
|||Ágoston G,Morvai-Illés B,Pálinkás A,Varga A, The role of stress echocardiography in cardiovascular disorders. Kardiologia polska. 2019 Nov 22; [PubMed PMID: 31647477]|
|||Pellikka PA,Roger VL,Oh JK,Miller FA,Seward JB,Tajik AJ, Stress echocardiography. Part II. Dobutamine stress echocardiography: techniques, implementation, clinical applications, and correlations. Mayo Clinic proceedings. 1995 Jan; [PubMed PMID: 7808046]|
|||Aggeli C,Polytarchou K,Varvarousis D,Kastellanos S,Tousoulis D, Stress ECHO beyond coronary artery disease. Is it the holy grail of cardiovascular imaging? Clinical cardiology. 2018 Dec; [PubMed PMID: 30315566]|
|||Kossaify A,Bassil E,Kossaify M, Stress Echocardiography: Concept and Criteria, Structure and Steps, Obstacles and Outcomes, Focused Update and Review. Cardiology research. 2020 Apr; [PubMed PMID: 32256915]|
|||Płońska-Gościniak E,Gackowski A,Kukulski T,Kasprzak JD,Szyszka A,Braksator W,Gąsior Z,Lichodziejewska B,Pysz P, Stress echocardiography. Part I: Stress echocardiography in coronary heart disease. Journal of ultrasonography. 2019; [PubMed PMID: 31088010]|
|||Mulvagh SL,Rakowski H,Vannan MA,Abdelmoneim SS,Becher H,Bierig SM,Burns PN,Castello R,Coon PD,Hagen ME,Jollis JG,Kimball TR,Kitzman DW,Kronzon I,Labovitz AJ,Lang RM,Mathew J,Moir WS,Nagueh SF,Pearlman AS,Perez JE,Porter TR,Rosenbloom J,Strachan GM,Thanigaraj S,Wei K,Woo A,Yu EH,Zoghbi WA, American Society of Echocardiography Consensus Statement on the Clinical Applications of Ultrasonic Contrast Agents in Echocardiography. Journal of the American Society of Echocardiography : official publication of the American Society of Echocardiography. 2008 Nov; [PubMed PMID: 18992671]|
|||Ntoskas T,Ahmad F,Woodmansey P, Safety and efficacy of physiologist-led dobutamine stress echocardiography: experience from a tertiary cardiac centre Echo research and practice. 2018 Sep 1; [PubMed PMID: 30303679]|
|||Badiani S,Waddingham P,Lloyd G,Bhattacharyya S, Stress echocardiography in valvular heart disease. Expert review of cardiovascular therapy. 2018 Nov; [PubMed PMID: 30286667]|
|||Picano E,Ciampi Q,Wierzbowska-Drabik K,Urluescu ML,Morrone D,Carpeggiani C, The new clinical standard of integrated quadruple stress echocardiography with ABCD protocol. Cardiovascular ultrasound. 2018 Oct 2; [PubMed PMID: 30285774]|
|||Berbarie RF,Dib E,Ahmad M, Stress echocardiography using real-time three-dimensional imaging. Echocardiography (Mount Kisco, N.Y.). 2018 Aug; [PubMed PMID: 30133883]|
|||Picano E,Sicari R,Varga A, Dipyridamole stress echocardiography. Cardiology clinics. 1999 Aug; [PubMed PMID: 10453294]|
|||Imran MB,Pálinkás A,Picano E, Head-to-head comparison of dipyridamole echocardiography and stress perfusion scintigraphy for the detection of coronary artery disease: a meta-analysis. Comparison between stress echo and scintigraphy. The international journal of cardiovascular imaging. 2003 Feb; [PubMed PMID: 12602478]|
|||Bigi R, Complications of pharmacologic stress echocardiography in coronary artery disease. Clinical cardiology. 1996 Oct; [PubMed PMID: 8896909]|
|||Mansencal N,Mustafic H,Hauguel-Moreau M,Lannou S,Szymanski C,Dubourg O, Occurrence of Atrial Fibrillation During Dobutamine Stress Echocardiography. The American journal of cardiology. 2019 Apr 15; [PubMed PMID: 30745020]|
|||Pinton R,Lemke W,Garcia LG, [Symptoms, complications and hemodynamic changes related to dobutamine stress echocardiography]. Arquivos brasileiros de cardiologia. 1997 Sep; [PubMed PMID: 9595726]|
|||Geleijnse ML,Krenning BJ,Nemes A,van Dalen BM,Soliman OI,Ten Cate FJ,Schinkel AF,Boersma E,Simoons ML, Incidence, pathophysiology, and treatment of complications during dobutamine-atropine stress echocardiography. Circulation. 2010 Apr 20; [PubMed PMID: 20404267]|
|||Hirano Y,Yamamoto T,Uehara H,Nakamura H,Wufuer M,Yamada S,Ikawa H,Ishikawa K, [Complications of stress echocardiography]. Journal of cardiology. 2001 Aug; [PubMed PMID: 11525112]|
|||Picano E,Alaimo A,Chubuchny V,Plonska E,Baldo V,Baldini U,Pauletti M,Perticucci R,Fonseca L,Villarraga HR,Emanuelli C,Miracapillo G,Hoffmann E,De Nes M, Noninvasive pacemaker stress echocardiography for diagnosis of coronary artery disease: a multicenter study. Journal of the American College of Cardiology. 2002 Oct 2; [PubMed PMID: 12383579]|