Exercise stress testing is recommended as the screening method to assess the probability of CAD after establishment of probable diagnosis based on the patient’s history, symptoms, ECG changes and cardiac biomarkers, especially in patient with intermediate pre-test probability of CAD. A 46 year old male with no previous CAD presented with retrosternal chest pain for the past 8 h. EKG showed global ST elevation, iSTAT troponin and first set of cardiac enzymes were negative 12 h after onset of chest pain. Echocardiogram was normal and treadmill exercise test was negative for ischemia. Second set of cardiac enzymes 18 h after chest pain onset was positive and EKG showed new T wave inversions. Thereafter a cardiac catheterization showed 100% occlusion of the left posterio-lateral branch of the left circumflex artery. Background: Exercise stress testing is most widely used, inexpensive, easy to perform screening method to assess the probability of CAD in intermediate patients with intermediate pre-test probability of CAD. Despite the wide use, it has its own shortcomings. Stress echocardiogram images however can be suboptimal in quality in 10–15% of the patients, is operator dependent and might lack reproducibility. A false negative result can also occur with lateral wall involvement secondary to left circumflex artery stenosis. In combination with various stressors, echocardiography provides a means of identifying myocardial ischaemia by detection of stress induced wall motion abnormalities. Therefore these caveats should be kept in mind when interpreting these results.