Stress echocardiography, with exercise or dobutamine pharmacologic stress, can be used to identify stress-induced ischemia. By providing information on the presence and location of wall-motion abnormalities related to a decrease in regional myocardial blood flow, the extent and location of ischemia can be defined.
The diagnostic role of stress echocardiography in women has been well established. Aggregate data analysis of over 1,000 women has shown a high accuracy for identifying physiologically significant CAD, with a mean sensitivity of 81% and a specificity of 86% [
7,
18,
19]. In symptomatic women who are incapable of exercise, dobutamine stress echocardiography reliably detects multivessel disease, with reported sensitivities from 75% to 93% and specificities of 79% to 92% [
7]. Based on recent studies, stress echocardiography with exercise or dobutamine stress is equally accurate for diagnosing physiologically significant CAD in women as in men. Stress echocardiography has been shown to be clinically useful for estimating cardiovascular prognosis in women [
18,
20,
21]. In a study evaluating 5-year survival in 4,234 female patients undergoing exercise stress echocardiography, survival in patients with no evidence of ischemia was found to be 99.4%, 97.6% with evidence of single-vessel ischemia, and 95% in the setting of multiple-vessel ischemia [
21]. Although an abnormal stress echocardiography correlates with a high cardiac event rate in women, a recent meta-analysis comparing dobutamine stress echocardiography to exercise single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) revealed a yearly rate of 0.75% of cardiovascular death and MI in the setting of a low-risk dobutamine echocardiography compared with 0.3% per year in low-risk exercise MPI [
22]. The authors concluded that in the ischemic cascade, perfusion abnormalities detected by SPECT MPI precede the wall-motion abnormalities seen with stress echocardiography. Wall-motion abnormalities often occur in the setting of advanced stenosis and with less predictability in areas supplied by mild-to-moderate coronary artery stenoses. Given the fact that an acute MI often presents in areas subtended by a less critical stenosis, stress echocardiography may underestimate risk in women with less advanced CAD. Therefore, in women, a negative or low-risk stress echocardiography has a higher cardiac death or MI rate compared with a low-risk stress MPI [
22].
Stress echocardiography in at-risk women has improved diagnostic and prognostic accuracy over exercise treadmill testing even when ECG stress interpretation is combined with the use of exercise capacity and hemodynamic data [
19]. Compared with other noninvasive cardiac imaging modalities (eg, SPECT, cardiac CT, coronary artery calcium [CAC]), a specific benefit of stress echocardiography for evaluating at-risk women is the absence of radiation exposure.