Stress echocardiography: from regional wall motion to multiparametric functional testing

The development of stress echocardiography reflects a diagnostic shift from ima­ging left ventricular wall motion during stress to the simultaneous assessment of multiple cardiovascular responses. This analytical review examines the method evolution through the following practical challenges addressed over time: the acquisition of two-dimensional images under stress, the standardization of physical and pharmacological protocols, the transition from ischemia diagnosis to prognostic assessment, and the integration of coronary, contractile, and chronotropic reserve evaluation, lung ultrasound, and quantitative assessment of left ventricular mechanics. The development of the ABCDE+ protocol is discussed separately, de­monstrating that this approach should be interpreted as a modular integration rather than a replacement for the classical assessment of regional wall motion. The review outlines the stages of the method’s development in Russia, the new Russian clinical guidelines for 2025-2026, the role of contrast enhancement, three-dimensional imaging, and artificial intelligence, as well as the issues currently hindering the full standardization of multiparametric stress echocardiography. The future of stress echocardiography lies in the standardization of quantitative parameters, the clinically justified selection of modules, the external validation of artificial intelligence algorithms, and incremental value of each new parameter.