BACKGROUND: Cardiac imaging stress tests have increased nearly 3-fold in the last decade, with >10 million a year performed in the United States alone. Inappropriate selection for testing may have important consequences because small individual costs (and risks) multiplied by millions of examinations represent a significant societal burden. The aim of this study was to assess the appropriateness of selection for stress echocardiography in 2 high-volume laboratories. METHODS: This audit of 350 consecutive stress echocardiograms for evaluation of known or suspected coronary artery disease was performed from May to June 2006 at centers in Australia and Italy. Appropriateness was independently scored by a senior clinical cardiologist as follows: I = definitely appropriate, IIa = probably appropriate, IIb = probably inappropriate, or III = definitely inappropriate, based on current guidelines for cardiac stress testing. All referrals were accepted at one center, and referrals were prescreened by cardiology fellows working at the other. RESULTS: Examinations were definitely appropriate in 217 (62%), probably appropriate in 35 (10%), probably inappropriate in 76 (22%), and definitely inappropriate in 22 (6%) patients. The main reasons of inappropriateness were (1) performance as first-line test (37% of inappropriate tests) and (2) test repeated too often in the absence of change in clinical status (30%). The inappropriate testing rate was higher when no screening of external referral was implemented (43% vs 13%, P < .0001). CONCLUSIONS: Inappropriate indications for stress echocardiography are common but avoidable if referrals are screened. Targeting inappropriateness opens a unique opportunity to cut health care expenditure with no reduction, and possibly improvement, in health care standards.