Stress Echocardiography in Aortic Stenosis: From Diagnostic Challenges to Guideline-Endorsed Clinical Applications

Aortic stenosis (AS) is the most common valvular heart disease in industrialized countries. Stress echocardiography (SE), using either exercise or dobutamine protocols, has emerged as a critical tool to overcome limitations of resting echocardiography, refine risk stratification, and guide the timing of aortic valve replacement. This review synthesizes contemporary evidence on the diagnostic, prognostic, and therapeutic role of SE in AS. Studies from all main databases (2000-2025) were systematically analyzed including prospective studies, consensus statements, and international guidelines. We highlight the physiological rationale, key prognostic markers, applications in asymptomatic severe and low-flow, low-gradient AS, and integration with multimodality imaging. SE is now guideline-endorsed for risk stratification in asymptomatic severe AS and the diagnosis of true severe versus pseudo-severe AS in low-flow, low-gradient disease. Future directions include advanced strain imaging, artificial intelligence, and broader adoption in the transcatheter era.