What Does a Stress Echo Show That a Normal Echo Doesn't?

A stress echocardiogram shows what a resting echocardiogram cannot: how the heart muscle behaves when it is working hard. Coronary artery disease — narrowed arteries — is often invisible at rest. Under stress, sections of muscle that are not getting enough blood stop contracting normally. That abnormality is visible on ultrasound.

According to Dr. Matt Balerdi, Consultant Cardiologist, a resting echo answers questions about structure and resting function. A stress echo answers a different question: is the heart receiving adequate blood supply during exertion?

Resting is not the whole story

Coronary artery disease — the narrowing or blockage of the arteries that supply blood to the heart muscle — is often invisible at rest.

At rest, the heart isn't working hard. If blood flow is reduced but not absent, the heart copes. The ultrasound images look normal. The patient feels fine.

It's only when demand increases — during exercise, or during a drug that mimics exercise — that the problem becomes visible. Sections of heart muscle that aren't getting enough blood start to move differently. They contract less well, or not at all.

That's what a stress echocardiogram is designed to find; we call this Regional Wall Motion Abnormalities

What's Actually Different

When a Stress Echo Adds Something a Resting Echo Doesn't

The most common reasons a stress echo is requested:

• Chest pain or tightness that comes on specifically with exertion
• Breathlessness during exercise that isn't explained by a resting echo, or other tests
• Known or suspected coronary artery disease, where the extent of the problem needs assessing
• Pre-operative cardiac assessment before major surgery
• Valve disease where it's important to understand how the valves behave under exercise conditions

In each of these situations, the resting echo has reached the limits of what it can answer. The stress echo picks up from there.

Safety

Stress echocardiograms are performed with a cardiologist present. The test is stopped at the first sign of any significant symptoms, ECG change, or echo abnormality.

Serious complications are very rare. The test is routinely performed in outpatient settings across the UK. The rate of serious complication are quoted between 1:1000 and 1:10,000 tests

A normal stress echocardiogram does not mean you are at no risk. Those with normal stress echo can still go one to have heart attacks. This event rate is 0.7% or 1:143 chance, les than that of the general population.

Frequently Asked Questions

Is a stress echo better than a standard echo?

Neither is better in absolute terms — they answer different questions. According to Dr. Matt Balerdi, Consultant Cardiologist, a resting echocardiogram is the correct first test for most cardiac symptoms. A stress echo is indicated when the question is whether the heart is receiving adequate blood supply during exercise.

How long does a stress echocardiogram take?

A stress echocardiogram takes 60 to 90 minutes. This includes a resting echo, the exercise or dobutamine phase, imaging immediately after peak stress, and a recovery period.

Is a stress echo safe?

Yes. The test is performed with a cardiologist present and stopped at the first sign of significant symptoms, ECG change, or abnormal imaging. Serious complications are very rare — estimated at 1 in 1,000 to 1 in 10,000 tests.

What does a stress echo feel like?

You exercise on a treadmill or bike, or receive a dobutamine infusion if you are unable to exercise. The ultrasound probe is placed on your chest at rest and again immediately after peak stress. The test is not painful.

Written by Dr Matthew Balerdi FRCP, Consultant Imaging Cardiologist. GMC: 6077164. Last reviewed: April 2026.