Clinical data and contrast stress echocardiography (CSE) results were analyzed in 283 patients to establish the prognostic value of CSE for patients with limited echocardiogram image quality at baseline. The mean follow-up period was 736 +/- 337 days. Only 7 patients (2.5%) had nondiagnostic image quality with contrast enhancement. During follow-up, 24 cardiac events (8.5%) occurred (5 cardiac-related deaths, 2 nonfatal myocardial infarction, 17 coronary revascularizations). Overall sensitivity, specificity, and positive and negative predictive values were 60.9%, 76.8%, 19.7%, and 95.5%, respectively. Kaplan-Meier event-free survival was higher for patients with a negative CSE result as compared with those with a positive CSE finding (P <.0001). In a multivariate Cox proportional hazards model, positive CSE was the strongest predictor of cardiac events (risk ratio 3.7; 95% confidence interval 1.6-8.7). CSE can successfully predict cardiac events for patients with limited noncontrast echocardiographic image quality. A negative CSE result conferred a good prognosis.