Two-dimensional (2D) stress echocardiography is well established in the assessment of patients with ischemic heart disease. However, in a number of patients, this technique results in nondiagnostic tests due to limited time available at peak stress to capture wall motion abnormalities. In order to obtain all segments of the left ventricle, the sonographer is expected to acquire multiple echocardiography views from multiple windows. The changes in heart rate during acquisition and the technical challenges in exactly matching the stress with the baseline 2D echocardiographic views may adversely impact the sensitivity of the test. Real-time three-dimensional (3D) stress echocardiography offers advantages in acquisition of all images from one echo window in a single capture, with the technique relatively easy to master. The current review will describe the 3D stress echocardiography technique, its advantages, and limitations. Additionally, the future direction of 3D stress echocardiography in detecting ischemia in patients with coronary artery disease will be discussed.