Stress echocardiography is a useful tool for the clinical decision making process, given its accuracy and demonstrated prognostic value. Among available stress echocardiography techniques, exercise is safer and more physiologic, therefore it must be considered the first choice for patients able to exercise. Peak exercise echocardiography has greater sensitivity than post-exercise imaging. Image quality of apical views at peak exercise is similar than that of images acquired during the immediate post-exercise period. Although more demanding than post-exercise treadmill imaging, the successfulness of peak treadmill exercise imaging may be improved with some skills. The role of new technology is promising for exercise echo. Doppler tissue and speckle imaging can assess myocardial velocities and deformation. However, although Doppler tissue imaging increases the agreement and accuracy among novel readers, it has not been demonstrated to be better than visual assessment when the latter is performed by experienced observers. Speckle imaging can easily measure myocardial torsion, which has been found to be altered under ischemic conditions. Finally, 3-dimensional echocardiography can also be used during exercise since a full volume of the entire myocardium can be obtained in a few cardiac cycles.