Stress echocardiography can play a key role in the diagnostic identification of the pathophysiological and prognostic heterogeneity underlying angina with normal coronary arteries. A stress for induction of coronary vasospasm (with ergometrine or hyperventilation) is required to exclude this condition as the cause of the symptoms, especially in patients with a clinical presentation suggestive of coronary vasospasm: angina also at rest and with highly variable exercise tolerance; marked seasonal and circadian variation, with worsening in springtime and early morning or worsening with beta-blockers; association with palpitations and syncope; ongoing therapy with methergin, 5-fluorouracil, or sumatriptan. After ruling out coronary vasospasm in selected patients, stress echocardiography is again useful for the stratification of three risk groups: low risk (no wall motion abnormalities, normal coronary artery flow reserve); intermediate risk (no wall motion abnormalities, reduced coronary flow reserve); high risk (inducible wall motion abnormalities). The assessment of wall motion can be made easily with all stresses (exercise, dobutamine, dipyridamole), whereas the evaluation of coronary flow is best performed with vasodilators (dipyridamole or adenosine). In patients at low risk, a special subset - to be systematically looked for in symptomatic athletes - probably at higher risk are those who develop a significant intraventricular gradient during exercise or dobutamine stress. In these patients, sport activity can theoretically pose a greater risk and beta-blockers might be warranted, possibly with a more consistent therapeutic benefit than in the overall population; however, more data are needed at this point.
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