[Stress echocardiography--principles, methodology, results and indications].

In the evaluation of coronary artery disease, conventional exercise testing remains the most important modality. Its diagnostic accuracy is reportedly around 70%. Which additional non-invasive examination should be chosen if the result of exercise testing is non-diagnostic? In myocardial ischemia, regional wall motion abnormalities occur before ECG-changes and angina. These regional wall motion abnormalities can be diagnosed and assessed echocardiographically at rest and after a physical or pharmacological exercise. Myocardial ischemia causes worsening of the wall motion if you compare stress with resting images. Stress echocardiography has a diagnostic accuracy of 85% in the assessment of coronary artery disease. When should we order stress echocardiography? If the resting ECG is normal and if the patient takes no digoxin, then conventional exercise testing is the preferred first line test. However, if the resting ECG is abnormal, if there is left ventricular hypertrophy, if there are ST/T-abnormalities, a Wolff-Parkinson White syndrome, a complete left bundle branch blockage or in patients who are unable to exercise adequately, stress echocardiography offers an excellent, accurate, cost-effective alternative with a lot of additional information regarding left ventricular muscle mass, pulmonary artery pressures or valvular heart disease. In very obese patients or patients with chronic obstructive pulmonary disease, echocardiographic image quality is reduced and nuclear perfusion imaging is definitely preferable. In most patients (95%), however, echocardiographic image quality is adequate for stress echocardiography. In patients with arterial hypertension, mitral valve prolapse, or in the need for additional information, stress echocardiography is preferable to nuclear imaging. In patients who are able to exercise, stress echocardiography in combination with bicycle or treadmill exercise should be chosen, only in patients who are unable to exercise adequately, pharmacological stress echocardiography--mainly dobutamine stress echocardiography--should be chosen. Hence, stress echocardiography has increasingly gained wide-spread use as an important and accurate diagnostic means in non-invasive cardiology. It is safe, not very costly, accurate and offers the unique opportunity of on-line assessment of the left ventricle. Indications for stress echocardiography include diagnosis and functional assessment of coronary artery disease, preoperative risk assessment before major vascular surgery, prognostic evaluation after myocardial infarction and viability assessment. In the next years, stress echocardiography will be used even more frequently and will become one of the most often used non-invasive methods in cardiology besides exercise testing.