Exercise ECG is an established method of evaluating the anti-ischemic properties of drugs. However, there are considerable methodologic limitations to this procedure and its use is restricted to patients with exercise-provoked ECG alterations which can be interpreted as ischemia. The principal, earlier onset of wall motion abnormalities according to the ischemic cascade can be detected by stress echocardiography and might be utilized as a pharmacological stress testing modality. Sixteen consecutive patients (15 men, one woman; 53 +/- 9 years old) with angiographically proven coronary artery disease (8 with one-, 5 with two-, and 3 with three-vessel disease) and exercise-induced wall motion abnormalities were examined by dynamic stress echocardiography (50 watt followed by 20-watt increases/min). Anti-ischemic drugs were withdrawn prior to and on day 1; on the following day 2, 0.2 microgram/kg/min nisoldipine was infused intravenously during the test after a 3 micrograms/kg bolus was given. At maximum comparable workload 15/16 patients showed an improved wall motion score on treatment (day 1: 22.9 +/- 4.9 vs day 2: 20.0 +/- 3.9; normal score: 12; one-sided binomial test: p = 0.0003). Eight of 16 patients demonstrated ST-segment deviations on day 1 and day 2. The double product did not differ at any workload stage until the maximum of 130 watt (day 1: 14,101 +/- 3140 vs day 2: 13,365 +/- 2865; n.s.). Dynamic stress echocardiography seems to be a valuable tool in pharmacologic stress testing and in terms of accuracy is supposed to be superior to conventional exercise ECG. Nisoldipine reduces exercise-induced wall motion abnormalities in patients with and without exercise-induced ECG alterations. The data result from a controlled pilot study, and further studies are required to confirm these promising methodological and therapeutic findings.