Contraindications for stress echocardiography are those that are present for either exercise testing (Chap. 4) or pharmacologic stress testing (Chap. 6). Absolute contraindications for cardiac stress testing include: hemodynamic instability, decompensated heart failure, acute myocardial infarction, including the presence of a new left bundle branch block, patient with acute chest pain and high pre-test probability of CAD, acute aortic dissection, high-risk unstable angina, and severe aortic stenosis symptomatic or with severe left ventricle (LV) enlargement or systolic dysfunction. Absolute indications to terminate stress testing include moderate to severe angina, sustained ventricular tachycardia, near syncope, drop in systolic pressure > than 10 mmHg from baseline in addition to other sings of ischemia [2, 3].

Relative contraindications rely on the technique and comorbidities. In about 5 % of cases, a poor acoustic window will severely limit the value stress echocardiography. A difficult resting echocardiogram serves as a cue that no interpretable results would be obtained during this test. Contrast administration should be considered for improved opacification of the LV cavity (Chap. 3). Additionally, some conditions may reduce the diagnostic accuracy of the test, including preexisting wall motion abnormalities that tether adjacent segments. Hypertrophic cardiomyopathy and other cardiomyopathies may also be problematic. Uncontrolled hypertension may also prevent attaining an adequate level of stress.

The stress portion of this procedure may be performed with exercise or with pharmacological stressors-all required equipment should therefore be present, as outlined in previous chapters.

Ultrasound contrast agents may be needed for either with exercise or pharmacological studies and should be administered when two or more segments are not well visualized to improve accuracy by opacifying the LV and enhancing the endocardial border, and reducing the frequency of equivocal findings (Chap. 3).

A blood pressure cuff is required for registering blood pressure at rest and during every stage of the test. A 12-lead ECG should be performed at rest with monitoring throughout the examination. For the echocardiographic images, an ultrasound system that permits one to one registration of images both during rest and stress to enable concomitant comparison is necessary. A workstation is then necessary for posttest analysis and interpretation, equipped with software that allows for split and quad-screen displays for concurrent comparisons of the images at the various stages of stress. This is essential to be able to elicit subtle wall motion changes. The advances in digital imaging also allow assessing multiple cardiac cycles during stress, hence improving interpretation analysis. Image backup is should be performed. Most importantly, highly qualified professionals that are skillful in the imaging technique should perform and interpret the study.

All methods of stress testing should include standardize protocols and monitoring of vital signs at rest and during stress, rest/stress ECG. A baseline echocardiogram is performed to assess for ventricular function, chamber sizes and pressures, wall-motion thickness, aortic root, and valves morphology and functionality and to screen for contraindications for the test, significant pathology, and to ensure adequate image quality [2, 3]. If endocardial resolution is not optimal in two or more segments, then intravenous contrast enhancement should be performed as described in Chap. 3. Subsequently, left ventricle images are obtained from two parasternal views: long and short, and apical-long axis, apical four-and two-chamber view both at rest and then at stress. Comparison of rest and stress images is performed to assess LV function and regional wall motion abnormalities.