Patients who are candidates for an exercise ECG must be able to exercise and must have an interpretable ECG, which is defined as a normal 12-lead ECG or one with minimal resting ST-T-wave abnormalities (,0.5 mm). 2.2.3.2. Exercise and Pharmacological Stress Echocardiography The diagnostic endpoint of exercise and pharmacological stress echocardiography is new or worsening wall motion abnormalities and changes in global LV function during or immediately after stress. In addition to the detection of inducible wall motion abnormalities, most stress echocardi- ography includes screening images to evaluate resting ven- tricular function and valvular abnormalities. This information can be helpful in a symptomatic patient without a proven diagnosis. Pharmacological stress echocardiography in the United States is performed largely by using dobutamine with an endpoint of inducible wall motion abnormalities (Table 11). Vasodilator agents such as adenosine are used rarely in the United States but are used more commonly in Europe. The diagnostic accuracy of exercise and pharmacological stress echocardiography has been studied extensively in multiple meta-analyses, systematic reviews, and large, multicenter, observational registries.91,148 152,154,175 In several contempo- rary meta-analyses, the diagnostic sensitivity (uncorrected for referral bias) ranged from 70% to 85% for exercise and 85% to 90% for pharmacological stress echocardiogra- phy.91,150,152,154 The uncorrected diagnostic specificity ranges Fihn et al Stable Ischemic Heart Disease: Full Text e377 from 77% to 89% and 79% to 90% for exercise and pharmacological stress echocardiography, respectively. The use of intravenous ultrasound contrast agents can improve endocardial border delineation and can result in improved diagnostic accuracy.181 Myocardial contrast echocardiogra- phy also has been examined for determination of rest and stress myocardial perfusion, with the results showing compa- rability to myocardial perfusion SPECT findings in small patient series.182 However, the technique is currently in limited use in the United States. 