Contrast stress echocardiography: completing the picture from image enhancement to improved accuracy and prognostic insight.

Echocardiographic contrast agents have great value in combination with stress echocardiography. Their conventional role is to enhance left ventricular borders during suboptimal imaging, and the test is widely, if not universally, applied for this purpose.1 The use of echocardiographic contrast agents unequivocally improves endocardial resolution,2,3 facilitating concordant test interpretation,4 and there are probable diagnostic benefits,5 especially for less-expert readers. The evaluation of myocardial perfusion with echocardiographic contrast agents, long considered a holy grail of echocardiography, has become feasible as a result of improved understanding of microbubble–ultrasound interaction, equipment development, and significant efforts from a relatively small number of clinical investigators. The development of a feasible approach for myocardial contrast echocardiography has led to a number of recent reports that demonstrate improvement in the accuracy of stress echocardiography,6,7 particularly for the identification of single-vessel disease, and the recognition of the true extent of coronary disease, a facet that is commonly underestimated with stress echocardiography.