Echocardiography remains the primary modality to identify cardiac structural and functional abnormalities in patients with signs and symptoms of heart failure. Echocardiography may also have a role in identifying patients at risk of heart failure, in other words, differentiating patients from ACC/AHA stage A (risk factors for heart failure) to stage B (structural abnormalities in the absence of symptoms). In recent years soluble (blood based) cardiac specific biomarkers have been broadly introduced into clinical practice for the diagnosis of acute myocardial infarction (cardiac troponins) and diagnosing and prognosticating patients with heart failure (the natriuretic peptide tests, B-type natriuretic peptide [BNP] and the amino-terminal of proBNP [NT-proBNP]). Specifically, a large number of studies have evaluated the use of natriuretic peptides to complement the results of echocardiography in a spectrum of cardiovascular diseases ranging from asymptomatic community based populations to prognosticating patients with cardiomyopathies, valve disease and pulmonary embolism. The focus of this review will be to assess the state of the evidence from a variety of scenarios where natriuretic peptide testing and echocardiography can provide complementary information for diagnosis, prognosis and potentially guiding therapy.