Ischaemic heart disease & post-MI
Regional wall motion by territory, viability, the mechanical complications of infarction, and LV thrombus.
Numbers to remember
- 17-segment model; WMSI = sum of segment scores ÷ segments seen (1 = normal) [1]
- ICD: LVEF ≤35% ≥40 days after MI and ≥90 days after revascularisation, NYHA II–III [11,38]
- STICH: CABG reduced 10-year death in EF ≤35%; viability did not identify who benefits [141,142]
- REVIVED-BCIS2: PCI did not reduce death or HF hospitalisation in EF ≤35% [143]
- Pseudoaneurysm: narrow neck (neck/maximal diameter <0.5), no myocardium in the wall
Questions echo must answer
In acute and chronic coronary syndromes, echo measures the extent and territory of dysfunction, LVEF for prognosis and device decisions, and the complications of infarction [138,139]. In the emergency department, a new regional wall-motion abnormality in chest pain supports ischaemia, and normal wall motion during pain makes it less likely [195].
- TerritoryRegional wall motion in the 17-segment model; which coronary artery? [1]
- Global functionBiplane LVEF, WMSI, GLS [1,89].
- Mechanical complicationsVentricular septal rupture, papillary muscle rupture, free-wall rupture or pseudoaneurysm, tamponade [138].
- Remodelling and thrombusAneurysm, LV thrombus (apical akinesis after anterior MI) [140].
- Ischaemic MRTethering (Carpentier IIIb) [4,186].
- Viability and ischaemiaDobutamine or exercise stress echo when it will change management [27,139].
Acquisition protocol
- Apical 4 / 2 / 3Score each of 17 segments (1 normal, 2 hypokinetic, 3 akinetic, 4 dyskinetic) and calculate WMSI. Biplane LVEF [1].
- PSAX sweepConfirm the regional pattern at basal, mid and apical levels. Measure wall thickness (≤6 mm with increased echogenicity = scar).
- ContrastUse contrast if two or more segments are not seen, and always if apical thrombus is suspected [1,140].
- Colour sweepScan the septum for a VSD jet (inferior MI = basal inferoseptum; anterior MI = apical septum) and the mitral valve for new MR.
- MitralLook for a flail leaflet or head of papillary muscle (rupture) versus tethering (chronic ischaemic MR). Quantify [4].
- PericardiumEffusion or thrombus. Any new effusion after MI with hypotension = rupture until proved otherwise.
- RVInferior MI → RV infarction: RV dilatation, low TAPSE, dilated IVC.
- Output and fillingSVI, CI, E/e′, TR velocity.
- Segmental scoring and WMSI
- Biplane LVEF, GLS
- Territory
- VSD, MR, rupture and effusion excluded
- Apical thrombus excluded (contrast)
- Aneurysm or pseudoaneurysm
- RV involvement
- SVI, CI, filling pressure
Diagnosis & severity
| Finding | Echo features | Implication |
|---|---|---|
| True aneurysm | Wide neck; wall is thinned myocardium; dyskinetic | Thrombus, VT, HF; rupture rare |
| Pseudoaneurysm | Narrow neck (neck/maximal diameter <0.5); wall is pericardium or thrombus; flow in and out on colour | Contained rupture: urgent surgery [138] |
| Ventricular septal rupture | Left-to-right colour jet across the septum; high systolic velocity; RV volume and pressure load | Surgical or transcatheter repair; mechanical support [138] |
| Papillary muscle rupture | Flail leaflet with muscle head; eccentric severe MR (may look small because of rapid pressure equalisation) | Emergency surgery [138] |
| LV thrombus | Echodense mass contiguous with akinetic segment, distinct from the endocardium; contrast shows no perfusion | Anticoagulation [140] |
| Chronic ischaemic MR | Tethered leaflets, tenting area, systolic tenting height | Treat LV first; TEER in the COAPT profile [64,186] |
Key pointWMSI and LVEF after MI predict mortality. An LVEF ≤35% after the waiting period is the main echo input to ICD decisions [38].
Thresholds that change management
- New regional wall-motion abnormality in active chest pain with a non-diagnostic ECG → supports an ischaemic cause. Proceed along the ACS pathway [138,195].
- Mechanical complication → emergency cardiac surgery and mechanical support. Echo is often the first test to find it [138].
- LVEF ≤35% → repeat at ≥40 days after MI (≥90 days after revascularisation) on optimal therapy before a primary-prevention ICD [12,38].
- Revascularisation in ischaemic cardiomyopathy → STICH showed a long-term survival benefit of CABG in EF ≤35% [141,142]. REVIVED-BCIS2 showed no benefit of PCI [143]. Viability testing did not identify who benefits from CABG in STICH, so it should not be used alone to deny revascularisation [139,141].
- LV thrombus → anticoagulation for about 3 months, then re-image [140].
Pitfalls & mimics
PitfallForeshortened apex = missed apical akinesis and thrombus. A false apex looks thick and contracts well. Use contrast liberally after anterior MI [1,140].
- Tethering by neighbouring segments makes a normal segment look hypokinetic, and vice versa. Judge wall thickening, not motion.
- Stunning versus scar: an akinetic segment early after reperfusion may recover. Do not make permanent decisions on day 1 [38].
- Takotsubo and myocarditis produce regional dysfunction in non-coronary distributions [133].
- LBBB, pacing and post-cardiac surgery produce abnormal septal motion without ischaemia.
- Papillary muscle rupture can look like "moderate" MR in low output. A flail leaflet with a mobile mass is the key [4].