Routine two dimensional echocardiography is one of the most commonly performed non-invasive tests in the USA and Europe. Key subsets of patients who undergo echocardiography are prone to having a suboptimal image, including obese patients, those with impaired pulmonary function, and elderly patients.1-3 A number of reviews have estimated that, on average, 10–15% of all routine echocardiograms are suboptimal.1-4 Ultrasound contrast agents that have been approved for use in Europe and the USA for evaluation of left ventricular opacification and endocardial border delineation include Optison and Levovist.5 In addition to better delineation of regional myocardial segments, clinical trials are under way to examine the efficacy of these agents for estimating myocardial perfusion.6 ,7 Although providing improved image quality, new advances in the field of ultrasound imaging must be viewed within our current era of limited resources and must be shown to provide added clinical and economic value before they can be assimilated into daily clinical practice.

Over the past two decades, large reductions in mortality and associated cardiovascular complications have been accomplished as a result of new therapeutics and devices in the treatment or prevention of coronary artery disease. New cardiovascular disease tests and treatments have resulted in profound reductions in mortality.8 In the USA and in Europe, a major factor contributing to the high costs of health care have been new therapeutic and technological advances. It is estimated that one third of the costs of care are attributable to new technology.9-13

With the integration and globalisation of world markets, the resulting free market economies increasingly dictate the organisation, financing, and delivery of health care. As a result of the development of new medical technology and treatments, the costs of health care rise. With higher health care costs, the resulting delivery and financing …