Stress Echocardiography

  • Harald Becher
  • Andreas Helfen


Contrast agents have enhanced the quality, reproducibility and accuracy of stress echocardiography. In addition to the assessment of LV wall motion myocardial perfusion can be evaluated with contrast agents. This chapter is aligned to the Clinical practice of contrast echocardiography: recommendation by the European Association of Cardiovascular Imaging (EACVI) 2017 and the 2018 American Society of Echocardiography Focused Update Regarding the Clinical Applications of Ultrasonic Enhancing Agents in Echocardiography. Following a brief overview of the principles of stress echocardiography, practical advice is given on How to perform an exercise stress echocardiogram with contrast agents in 10 steps and How to perform a dobutamine stress echocardiogram with contrast agents in 10 steps. The indications for contrast agents, the appropriate imaging modalities, machine settings, imaging planes and dosages of the contrast agents are provided for assessment of LV wall motion only and for combined analysis of LV wall motion and myocardial perfusion.

Supplementary material

Video 5.1

Assessment of the image quality to determine whether contrast agents are indicated. 4-chamber view (top right), 2-chamber view (top left), apical long axis (bottom left) and parasternal short axis view (bottom right). The endocardial delineation of the endocardium and myocardial thickening in the anterior and anteroseptal segments regions is suboptimal. Therefore a contrast agent has to be used (AVI 32023 kb)

Video 5.2

Example of adequate recordings at rest. Homogeneous LV opacification of the LV cavity and excellent endocardial delineation on the end-systolic still frames. Minor opacification of the myocardium. 4-chamber view (top left), 2-chamber view (top right), apical long axis view (bottom left), short axis (bottom right) (AVI 9558 kb)

Video 5.3

Evaluation of the regional LV wall motion on a quad screen, 4 chamber view: Rest (top left), 25 Watts (top right), 75 Watts (bottom left) and in early recovery phase (bottom right) (AVI 9761 kb)

Video 5.4

Anterior septal akinesis evident already at 25 Watts (top right). At rest and in recovery normal wall motion in the 3-chamber view (top left and bottom left) (AVI 13498 kb)

Video. 5.5

4-chamber view during dobutamine stress infusion of SonoVue® (diluted 1:1, 1.5 mL/min). Rest (top left) 10 μg/kg/min (top right), peak stress (bottom left) and early recovery (bottom right). Normal LV wall motion (AVI 9750 kb)

Video. 5.6

Adequate recordings at rest: 4-chamber view (top left), 2-chamber view (top right), apical long axis or 3-chamber view (bottom left) and parasternal short axis section (right below) (AVI 9184 kb)

Video. 5.7

Adequate recording at peak stress: note the increased brightness of the myocardium due to hyperemia. 4-chamber view (top left), 2-chamber view (top right), apical long axis or 3-chamber view (bottom left) and parasternal short axis section (right below) (AVI 7895 kb)

Video 5.8

Modified dobutamine stress protocol for assessment of myocardial perfusion. Note the recordings of flash-replenishment sequences in the early recovery phase instead of acquiring single beat loops. Apart from these recordings the protocol is not different from the protocol, which is applied for assessment of LV wall motion only (AVI 57944 kb)

Video 5.9

Flash replenishment sequence lasting 10 cardiac cycles, the FLASH is initiated after two cardiac cycles (left). The “slow motion” recording shows intense brightness of the entire imaging sector during the FLASH (right). After the FLASH the myocardium is dark while there is still opacification of the entire LV cavity. Within 3 heart cycles (<2 s) the contrast in the myocardium is replenished (AVI 84467 kb)

Video 5.10

Quadscreen for the assessment of the regional LV wall movement. Simultaneous display of the 4-chamber view at the different stages of stress. According to the 2015 EAE/ASE Recommendations for Chamber Quantification, the segments should be classified by wall thickening and endocardial movement. The myocardial opacification facilitates the assessment of the systolic thickening. When myocardial opacification is poor, there is often still detectable opacification of the larger epicardial vessels, which allows assessment of systolic wall thickening (AVI 9420 kb)

Video 5.11

Quad screen for the assessment of the regional LV wall motion in the 2-chamber view (AVI 9833 kb)

Video 5.12

Quad screen for the assessment of the regional LV wall motion in the 3-chamber view (AVI 9780 kb)

Video 5.13

Quad screen for the assessment of the regional LV wall motion in short axis view (AVI 8373 kb)

Video 5.14

Severe ischemia of the posterior wall and the anteroseptum: The systolic image recorded at low-dose dobutamine shows uniform contrast of the myocardium (left). At higher dobutamine dose, the patient complained of typical angina pectoris. The apex became akinetic. A subendocardial perfusion defect can be seen involving the apex as well as the mid anteroseptum and mid posterior wall (right) (AVI 9480 kb)

Video 5.15

Patient with severe LAD stenosis, 4-chamber view: At rest (top left) inhomogeneous myocardial opacification, at 10 μg/kg/min dobutamine (top right) there is enhanced myocardial opacification with poor opacification only of the basal lateral segment (pseudo effect). At a heart rate of 95/min, the patient experienced severe angina and a subendocardial perfusion defect was visualized in the two apical segments. The septal apical segment became hypokinetic. The wall motion of apical lateral segment was normal (AVI 5823 kb)

Video 5.16

2-chamber view, same patient as in Fig. 5.41. At rest (top left) good delineation of the LV-cavity, poor myocardial opacification. At 10 μg/kg/min dobutamine adequate opacification of the inferior wall and of the mid anterior wall but perfusion defect in the apical anterior segment (top right). When the patient complains on angina (bottom left) a typical perfusion defect can be seen in the apical anterior segment. The wall motion was still normal. The lacking opacification in the basal anterior segment represents a pseudo-defect (see text) (AVI 5214 kb)

Video 5.17

Low-dose dobutamine stress-echocradiography in a patient with severe proximal LAD stenosis and heart failure, 4-chamber view at rest (top left), 5 μg/kg/min (top right), 10 μg/kg/min (bottom left) and 20 μg/kg/min (bottom right). The mid and apical septum as well as the apical lateral wall are akinetic. There is no change during infusion of the tree dosages of dobutamine. Note the lack of opacification in the akinetic segments. PCI of the LAD is not indicated (AVI 8157 kb)


  1. ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR. Appropriate use criteria for echocardiography. JASE. 2011;24:229–67.Google Scholar
  2. Deutschen Gesellschaft für Kardiologie. Leitlinien zur Ergometrie herausgegeben vom Vorstand der Deutschen Gesellschaft für Kardiologie. Z Kardiol. 2000;89:821–37.CrossRefGoogle Scholar
  3. ESC. Guidelines on the management of stable coronary artery disease. Eur Heart J. 2013;34(38):2949–3003.CrossRefGoogle Scholar
  4. Gaibazzi N, Bianconcini M, Marziliano N, et al. Scar detection by pulse-cancellation echocardiography. Validation by CMR in patients with recent STEMI. JACC Cardiovasc Imaging. 2016;9(11):1239–51.CrossRefGoogle Scholar
  5. Gulati M, Shaw LJ, Thisted RA, Black HR, Bairey Merz CN, Arnsdorf MF. Heart rate response to exercise stress testing in asymptomatic women: the St. James women take heart project. Circulation. 2010;122:130–7.CrossRefGoogle Scholar
  6. Helfen A, Becher H. Contrast echocardiography – educational tool. Heidelberg, Berlin: Springer; 2016.. Google Scholar
  7. Jain M, Nkonde C, Lin BA, et al. 85% of maximal age-predicted heart rate is not a valid end-point for exercise treadmill testing. J Nucl Cardiol. 2011;18:1026–35.CrossRefGoogle Scholar
  8. Larsson MK, et al. The potential clinical value of contrast enhanced echocardiography beyond current recommendations. Cardiovasc Ultrasound. 2016;14:2.CrossRefGoogle Scholar
  9. Makani H, Bangalore S, Halpern D, et al. Cardiac outcomes with submaximal normal stress echocardiography. J Am Coll Cardiol. 2012;60:1393–401.CrossRefGoogle Scholar
  10. Mehrotra P, Labib SB, Schick EC. Differential effects of dobutamine versus treadmill exercise on left ventricular volume and wall stress. J Am Soc Echocardiogr. 2012;25:911–8.CrossRefGoogle Scholar
  11. Neumann F-J, Sousa-Uva M, Ahlsson A, et al. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J. 2019;40(2):87–165.CrossRefGoogle Scholar
  12. Plana JC, Mikati IA, Dokainish H, et al. A randomized cross-over study for evaluation of the effect of image optimization with contrast on the diagnostic accuracy of dobutamine echocardiography in coronary artery disease The OPTIMIZE Trial. JACC Cardiovasc Imaging. 2008;1(2):145–52.CrossRefGoogle Scholar
  13. Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JG, Coats AJ, Falk V, González-Juanatey JR, Harjola VP, Jankowska EA, Jessup M, Linde C, Nihoyannopoulos P, Parissis JT, Pieske B, Riley JP, Rosano GM, Ruilope LM, Ruschitzka F, Rutten FH, van der Meer P. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: the task force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J. 2016;37(27):2129–000.CrossRefGoogle Scholar
  14. Porter T, et al. Guidelines for the cardiac sonographer in the performance of contrast echocardiography: a focused update from the American Society of Echocardiography. J Am Soc Echocardiogr. 2014;27:797–810.CrossRefGoogle Scholar
  15. Porter TR, Mulvagh SL, Abdelmoneim SS, Becher H, Belcik JT, Bierig M, Choy J, Gaibazzi N, Gillam LD, Janardhanan R, Kutty S, Leong-Poi H, Lindner JR, Main ML, Mathias W Jr, Park MM, Senior R, Villanueva F. Clinical applications of ultrasonic enhancing agents in echocardiography: 2018 American Society of Echocardiography Guidelines Update. J Am Soc Echocardiogr. 2018 Mar;31(3):241–74.CrossRefGoogle Scholar
  16. Schwaab B, Franz I-W. Herz-Kreislauf-Krankheiten. Sozialmedizinische Begutachtung für die gesetzliche Rentenversicherung. Berlin, Heidelberg: Springer; 2011. p. 289–324.CrossRefGoogle Scholar
  17. Senior R, Becher H, Monaghan M, Agati L, Zamorano J, Vanoverschelde JL, Nihoyannopoulos P, Edvardsen T, Lancelloti P. Clinical practice of contrast echocardiography: recommendation by the European Association of Cardiovascular Imaging (EACVI). Eur Heart J Cardiovasc Image. 2017 Nov 1;18(11):1205.CrossRefGoogle Scholar
  18. Sicari R, Nihoyannopoulos P, Evangelista A, et al. Stress echocardiography expert consensus statement. European Association of Echocardiography (EAE). Eur J Echocardiogr. 2008;9:415–37.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Harald Becher
    • 1
  • Andreas Helfen
    • 2
  1. 1.University of Alberta HospitalEdmontonCanada
  2. 2.St. Marien Hospital, Katholisches Klinikum Lünen GmbHLünenGermany

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