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Non-invasive imaging
Setting up a stress echo service: best practice
  1. Mathivathana Indrajith,
  2. Madalina Garbi,
  3. Mark J Monaghan
  1. Cardiac Non-Invasive Diagnostics Department, King's College Hospital NHS Foundation Trust, London, UK
  1. Correspondence to Professor Mark J Monaghan, King's College Hospital NHS Foundation Trust, London, SE5 9RS, UK; mark.monaghan{at}

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Learning objectives

  • Understanding the process of stress echo service development and the influencing factors.

  • Learning the requirements of a stress echo service.

  • Acknowledging the recommendations and guidelines underpinning a stress echo service.


Stress echocardiography (SE) is well established in the assessment of ischaemic heart disease (IHD),1 ,2 and is used to detect ischaemia due both to epicardial coronary disease and microvascular disease. Furthermore, SE has an evolving role in the assessment of non-IHDs such as cardiomyopathies, valvular heart disease, pulmonary hypertension, heart transplant, congenital heart disease and athlete's heart.3 To rise up to the challenge of assessing more than only regional wall motion abnormalities (RWMAs), all echocardiographic techniques, both old and new, are currently used in SE (M-mode, two-dimensional (2D), pulsed, continuous and colour Doppler, lung ultrasound, 3D echo, 2D speckle tracking and myocardial contrast echo). The SE protocol is adapted according to the indication and for each particular case.3

There is a wealth of evidence regarding the diagnostic value of SE in IHD and in support of the evolving indications.1–9 Furthermore, there are guidelines, recommendations and appropriateness criteria regarding stress echo clinical indications and the procedure itself.2 ,4 ,5 ,6 ,8 However, there is limited literature to consult when developing a stress echo service; therefore, we compiled this guide in order to fill in this literature gap.6

When developing a new service, we have to take into consideration demand, capacity, competing techniques, commissioning, local policy for accepted indications, contraindications, and management of complications, types of stress echo to be performed, required space, equipment, consumables and staffing, reporting, audit and potential research.

The demand depends on the population covered, the guidelines followed, the agreed referral pathways, the agreed accepted indications and the coexistence of services providing an alternative functional test. The …

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  • Contributors All authors have contributed equally to writing this article.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; externally peer reviewed.

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