Stress electrocardiographic (ECG) ST-segment depression is a prognostic marker of adverse cardiac outcomes in coronary artery disease. However, use of concurrent stress echocardiography (ECHO) has lead to concordant and discordant findings on stress electrocardiogram during stress studies. The prognostic value of stress ECHO in the setting of these stress ECG findings has not been previously evaluated. Outcomes of 1,268 patients (60 +/- 12 years old, 48% women) who had normal electrocardiograms and underwent stress ECHO were analyzed. ST-segment depression > or =1.5 mm in 2 contiguous leads on stress electrocardiogram and a wall motion score index of >1 on peak stress echocardiogram were considered abnormal. Events of nonfatal myocardial infarction (n = 18) and cardiac death (n = 32) were analyzed during follow-up (2.8 +/- 0.9 years). In 91 patients (7%) who had abnormal findings on stress electrocardiogram, 38 (41%) had an abnormal finding on stress echocardiogram and 4 had cardiac events (0.6% per year), and all who had a normal finding on stress echocardiogram had no events (n = 53, 59%, p = 0.01). Among 46 events (92%) with a normal finding on stress electrocardiogram, 30 (60%) showed a discordantly abnormal finding on stress echocardiogram (3.2% per year, p <0.01). Overall, the cohort that had normal findings on stress echocardiogram showed a lower event rate (72%, 16 events, 1.1% per year) compared with the cohort that had abnormal findings on stress echocardiogram (28%, 34 events, 3.6% per year, p <0.001), independent of stress ECG response. Peak wall motion score index (hazard ratio 2.55, p <0.001) and left ventricular ejection fraction (hazard ratio 0.99, p <0.001) were independent and incremental (global chi-square, p <0.001) prognostic markers by stress ECHO. In conclusion, a normal finding on stress echocardiogram confers a benign prognosis independent of the type of stress ECG response during stress studies. In addition, peak wall motion score index and ejection fraction by ECHO are stronger prognostic markers over stress electrocardiography in patients who are evaluated for coronary artery disease.