OBJECTIVE The aims of this study were: 1) to assess the relative prognostic value of predischarge dobutamine echocardiography (DE) and exercise electrocardiography (EE) in patients after a first uncomplicated acute myocardial infarction (AMI), and 2) to evaluate the optimal prognostic strategy by using the two tests in different combinations. METHODS DE (dobutamine infusion 5 to 40 micrograms/kg/min plus atropine 0.25 to 1 mg, if needed) and symptom-limited bicycle EE were performed in 208 patients (mean age 58 +/- 9 years, 90% males), on different days and in random order, 12 +/- 4 days after a first uncomplicated AMI and after pharmacological washout. A stress-induced dyssynergy and ST segment depression > 1 mm were considered criteria of positivity for DE and EE, respectively. Only spontaneous cardiac events were considered: cardiac death, reinfarction (= hard events), and unstable angina requiring hospitalization (= soft events). RESULTS Thirty-eight events occurred during follow-up (16 +/- 13 months; range: 1-44 months); 5 cardiac deaths, 6 reinfarctions and 27 unstable angina. Patients with a positive DE had a twofold increase in all event rates (26 vs 12%, p < 0.01) and a fourfold increase in the rate of hard events (9 vs 2%, p < 0.05). In contrast, no statistically significant difference was observed in the distribution of the same events between patients with positive and negative EE. Both tests showed similar negative (DE 88%, EE 85%) and positive (DE 26%, EE 24%) predictive values. Among six different strategies (performing either DE or EE only in all patients; EE in all patients; EE in all patients and DE only in those with a positive EE; and DE only in those with a negative EE; EE in all patients and DE only in those with anterior AMI), EE only in patients with inferior or non-Q AMI and DE only in those with anterior AMI), performing DE only in patients with a positive EE gave the highest predictive accuracy-74% (95% confidence intervals 68 to 80) for all events and 77% (95% confidence intervals 71 to 83) for hard events. CONCLUSIONS In patients with a first uncomplicated AMI, DE is useful in identifying patients at high and low risk of future spontaneous cardiac events. The optimal strategy for prognostication of these patients is to perform EE in all and DE only in the ones with a positive EE.