The safety of the stress test is a major issue in deciding its practicability and cost-effectiveness – yet, many major complications remain "unmentioned and unheard", for several reasons – mainly related to the "file drawer" bias, lack of time ("busy agenda bias") or unfamiliarity with the technicalities of scientific communication (editorial "black box bias").

Stress echocardiography is a cost-effective tool for the modern noninvasive diagnosis of coronary artery disease [1]. Several physical and pharmacological stresses are used in combination with echocardiographic imaging, usually exercise, dobutamine and dipyridamole. The safety of a stress is (or should be) a major determinant in the choice of testing. Although large scale single center experiences and multicenter trial information are available for both dobutamine and dipyridamole [2–6] stress echo testing, complications or side effects still can occur even in the most experienced laboratories with the most skilled operators. We believe that, in this field, every past complication described is a future complication avoided; what happens in your lab is more true than what you read in journals; and Good Clinical Practice is not "not having complications", but to describe the complications you had. Therefore, we decided to present an unusual case series, consisting in a collection of severe complications during pharmacological stress echo testing.

As stated in the American College of Cardiology/American Heart Association Clinical Competence Statement on Stress Testing, cognitive skills are required to attain competence in the direct supervision of stress echocardiographic tests, but not only the knowledge of the complications of different pharmacological agents but also the knowledge of their complication rate is important [7]. Therefore, both the patient and the physician, should be fully aware of the rate of complications during the application of all forms of stress. It is our stress policy, in the everyday echo lab activity, to strictly adopt the following criteria based on conventional wisdom and evidence-based medicine: 1) Avoid contraindications; 2) Never exceed standard dosages; 3) Perform the test after signed information consent has been obtained; 4) There must always be an attending physician; 5) Outpatients should be kept for 60' in the waiting room after testing; 6) Indications for testing must be class first class.