Given the above, it should come as little surprise that contrast use has been shown to improve the diagnostic accuracy of stress echocardiography, during both exercise  and pharmacological [11-12] stress. Although contrast use itself has some associated cost, an accurate test result can prevent further unnecessary investigations  and the cost savings of using contrast stress echocardiography for risk stratification (including early discharge) in patients admitted to hospital with chest pain has been demonstrated . Inter-observer variability of image interpretation is also reduced by contrast administration. A retrospective analysis of over 18000 patients who received contrast during stress echocardiography found that the diagnostic accuracy in those with sub-optimal image quality receiving contrast was equivalent to those with optimal image quality, demonstrating the efficacy and safety of using contrast during stress imaging .
Consequently, the EAE guidelines for contrast echocardiography  recommend contrast use when two or more endocardial borders of contiguous segments are not well visualized in order to:
- Obtain diagnostic assessment of systolic wall thickening at rest and at stress
- Increase the proportion of diagnostic studies
- Increase reader confidence in image interpretation