AIMS: This review explores the balance between the incremental data supplied by stress echocardiography and its cost. This technique is now established as an accurate tool for the diagnosis of coronary artery disease and myocardial viability, but the current medical-economic environment mandates careful consideration of the impact of the results on patient outcomes. METHODS AND RESULTS: The tools for assessment of cost and efficiency are reviewed. Two considerations are explored for controlling costs; avoidance of testing in those who will derive limited incremental data, and appropriate selection of stress echocardiography rather than other stress techniques. The balance between diagnostic accuracy and cost is explored in observational studies and computer models. Finally, the prognostic implications of testing are evaluated and data from the stress testing literature are explored to show that more effective patient selection for interventions may justify greater expenditure on testing. CONCLUSIONS: The appropriate selection of patients for testing has a significant evidence base. The cost of identifying coronary disease has been examined in a number of studies and facilitates the selection between testing modalities. Prognostic data are increasingly available, and further work is needed to combine this with cost analysis in order to show that stress echocardiography, like other stress modalities, may be used to guide therapy and thereby improve cost-effective outcomes.