Indications for Echocardiography After Stress Testing

Diagnostic Considerations

The American College of Cardiology recommends that an echocardiogram is not routinely needed after a stress test if the stress test results are normal and interpretable, especially in patients who can exercise, have an interpretable electrocardiogram, and have not had prior revascularization 1, 2
An echocardiogram may be necessary when ECG changes of ischemia are obscured by baseline abnormalities, such as left ventricular hypertrophy or resting repolarization changes, according to the American College of Cardiology 3, 4
The American College of Cardiology suggests that echocardiography can be used when stress test results are equivocal or indeterminate 4
Patients with left bundle-branch block or electronically paced ventricular rhythm may require echocardiography, as recommended by the American College of Cardiology and the Annals of Internal Medicine 5
Echocardiography can provide additional information about the location of ischemic myocardium and the size of the territory at risk, according to the American College of Cardiology 4
The American College of Cardiology recommends pharmacological stress with echocardiography for patients who are unable to exercise 4

The American Heart Association and the American College of Cardiology suggest that adding echocardiography to stress testing provides greater diagnostic accuracy than exercise ECG alone, with a strength of evidence level of I (high) 4
Echocardiography allows visualization of wall motion abnormalities that indicate ischemia, according to the European Society of Cardiology 6
The American College of Cardiology recommends that echocardiography can help identify abnormalities suggestive of myocardial ischemia or necrosis, such as segmental hypokinesia or akinesia, with a strength of evidence level of IIa (moderate) 7
Normal results on exercise echocardiography indicate a low cardiovascular event rate (<1% per year), as reported by the American Heart Association 8
The American College of Cardiology suggests that echocardiography can identify high-risk features, such as extensive rest wall-motion abnormalities or extensive ischemia, with a strength of evidence level of IIb (low-moderate) 8

The American College of Cardiology recommends that stress echocardiography can assess left ventricular function during exercise in patients with valvular heart disease, with a strength of evidence level of I (high) 4
Echocardiography can help evaluate changes in transvalvular gradient during exercise in patients with valvular heart disease, according to the American College of Cardiology 4
The American College of Cardiology suggests that stress echocardiography is particularly valuable in patients whose symptoms are out of proportion to the severity of valve disease at rest, with a strength of evidence level of IIa (moderate) 4

The American College of Cardiology recommends performing a standard exercise stress test if the patient can exercise, has an interpretable ECG, and no prior revascularization, with a strength of evidence level of I (high) 1, 2
If the stress test is clearly normal, no additional imaging is needed, according to the American College of Cardiology 1
If the stress test is clearly high-risk, proceed to coronary angiography, as recommended by the American College of Cardiology 2
If the stress test results are equivocal or uncertain, add imaging (echocardiography or nuclear), according to the American College of Cardiology 2
If the patient has baseline ECG abnormalities, use exercise imaging testing from the start, as recommended by the Annals of Internal Medicine 5
If the patient cannot exercise, use pharmacologic stress with imaging (echocardiography or nuclear), according to the Annals of Internal Medicine 5