OBJECTIVE: The goal of this study was to determine whether wall stress at rest and during stress could explain the influence of left ventricular (LV) morphology on the accuracy of dobutamine stress echocardiography (DSE). BACKGROUND: The sensitivity of DSE appears to be reduced in patients with concentric remodeling, but the cause of this finding is unclear. METHODS: We studied 161 patients without resting wall motion abnormalities who underwent DSE and coronary angiography. Patients were classified into four groups according to relative wall thickness (normal <0.45) and LV mass (normal =131 g/m(2) in men and =100 g/m(2) in women): normal geometry, concentric remodeling, concentric hypertrophy, and eccentric hypertrophy. Significant coronary artery disease was defined as >/=50% stenosis. Circumferential (cESS) and meridional end-systolic wall stress (mESS) were calculated at rest and peak DSE. RESULTS: Both false-negative and false-positive results for DSE were present in 35 patients (22%). The accuracy of DSE in patients with concentric remodeling (61%) was lower than that in patients with normal geometry (85%, p < 0.05) or concentric hypertrophy (86%, p < 0.05), but the accuracy with eccentric hypertrophy (64%, p < 0.05) was lower than with concentric hypertrophy. Patients in lowest quartile of cESS and mESS at peak had significantly lower sensitivity and accuracy than those in the highest quartile. A reduced cESS at peak (p = 0.012), presence of concentric remodeling (p = 0.044), and eccentric hypertrophy (p = 0.012) were significant predictors of both false-negative and false-positive results for DSE. CONCLUSIONS: The accuracy of DSE is influenced by the LV geometric pattern and peak wall stress.