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Non-invasive imaging
Stress echocardiography in the assessment of native valve disease
  1. Rajdeep S Khattar1,2,
  2. Roxy Senior1,2
  1. 1 Department of Echocardiography, Royal Brompton Hospital, London, UK
  2. 2 National Heart and Lung Institute, Imperial College, London, UK
  1. Correspondence to Professor Roxy Senior, Department of Echocardiography, Royal Brompton Hospital, London SW3 6NP, UK; roxysenior{at}

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Learning objectives

  • To understand the pathophysiological basis for stress echocardiography as a diagnostic tool for the evaluation of native valve disease.

  • To appreciate the methodological considerations and individualised protocols for stress echocardiography in each type of valve lesion.

  • To recognise the role of stress echocardiography in clinical decision making and prognosis with reference to guidelines for indications of stress echocardiography and management of valve disease.


Stress echocardiography is an established technique for the detection of coronary artery disease, but the echocardiographic assessment of valve disease has conventionally been performed under static conditions. However, valve disease also tends to present with exertional symptoms, influenced by changes in haemodynamic conditions provoked by normal physical activity. The changes in heart rate, contractility, loading conditions and left ventricular (LV) compliance during exercise may influence the haemodynamic significance of a given valve lesion. Consequently, in recent years the role of stress echocardiography in valve disease has been studied widely.1–6 The evaluation of valve disease under haemodynamic stress permits the detection of changes in transvalvular gradients, severity of regurgitation, LV contractility, pulmonary artery pressure and concomitant myocardial ischaemia. As valve disease tends to progress slowly, symptoms may develop insidiously, and many patients may either be unaware of the subtle changes in effort tolerance or regard any changes to be non-specific. Stress echocardiography with physiological exercise is uniquely placed, beyond other imaging modalities, in enabling an objective assessment of functional capacity and correlation of symptoms with the severity of valve disease and LV contractile response.

In general terms, a severe valve lesion causing symptoms or LV dysfunction usually warrants intervention.7 8 However, management may be unclear in those with severe valve disease without symptoms, non-severe valve disease with symptoms or valve disease with low flow. Under these circumstances stress echocardiography may provide additional information, helpful in the decision-making …

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  • Contributors RSK was responsible for the writing and compilation of the resources for the manuscript. RS provided academic input and was involved in the presentation and editing of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; externally peer reviewed.

  • Author note References which include a * are considered to be key references.

  • Patient consent for publication Not required.