The role of two-dimensional stress echocardiography (2D-SE) is well established for diagnosis and prognosis of patients with known or suspected coronary artery disease. 2D-SE has its limitations as multiple views of the left ventricle (LV) must be obtained within 90 seconds of peak stress from more than window to completely visualize all LV segments. 2D-SE is operator-dependent and requires advanced skills to match the same myocardial segments during stress. LV foreshortening is a frequently encountered problem in 2D-SE that may result in false negative studies. Real time three-dimensional SE (RT-3D-SE) can overcome many limitations of 2D-SE. In 3D-SE, overall wall motion of the entire LV is assessed simultaneously in different planes. 3D images can be displayed in multiplane or multislice views for ease of comparison with greater accuracy and interobserver agreement when compared to 2D. 3D-SE is quantitative, provides rapid image acquisition, requires lower level of operator skills, and avoids LV foreshortening by correct alignment of imaging planes. 3D-SE is easily applied during pharmacologic stress and is feasible during exercise-induced stress. Despite these advantages, 3D has lower temporal and spatial resolution than 2D and requires longer analysis time. With advances in transducer technology, smaller matrix footprints, and automated softwares, 3D full LV volume image acquisition can be obtained with a single beat that is less prone to artifacts. We will discuss the current application of RT-3D-SE, highlight the pros and cons of 3D-SE over conventional 2D-SE, and review major studies on 3D-SE and future implications.