Regional wall motion & stress echo

Seventeen segments, three coronary territories, thickening not motion — and a quiz to train your eye.

Numbers to remember

• Score each of 17 segments: 1 normal, 2 hypokinetic, 3 akinetic, 4 dyskinetic; wall motion score index = sum ÷ segments scored ^[1,27]
• Judge thickening, not inward motion: tethered or translated segments move without thickening ^[1,27]
• Thin (<6 mm), bright, akinetic segments are scar and unlikely to recover ^[27]

Questions echo must answer

Regional wall-motion assessment is the core of echo in ischaemic heart disease, at rest and during stress ^[27,139].

1. Which segments, how abnormal?Score thickening and endocardial excursion in the 17-segment model ^[1].
2. Which coronary territory?Anterior, septal and apical segments: LAD. Inferior and basal septum: RCA. Lateral and posterior: circumflex — with individual variation ^[1,27].
3. Viable or scar?Wall thickness, brightness, and response to low-dose dobutamine ^[27].
4. Global consequencesEF, mitral regurgitation, thrombus, aneurysm ^[140].

Acquisition protocol

1. PLAX, PSAX at mitral, papillary and apical levels, A4C, A2C, A3CEvery segment in two views ^[17].
2. Frame the LV fullyAvoid foreshortening the apex; use contrast if two or more segments are not seen ^[27].
3. Look at thickeningWatch the endocardium and the wall from end-diastole to end-systole, frame by frame if needed.
4. Stress echoSame views at rest, low dose, peak and recovery, side by side in quad screen ^[27,28].

• All 17 segments scored
• Contrast if ≥2 segments not seen
• Territory assigned
• Thrombus, aneurysm, MR checked

Diagnosis & severity

Stress echo: a segment that worsens with stress indicates ischaemia; an akinetic segment that improves at low dose and worsens at peak (biphasic) indicates viable, ischaemic myocardium ^[27].

Thresholds that change management

• New regional abnormality with chest pain → acute coronary syndrome pathway ^[138].
• Ischaemia in ≥3 of 16 segments on stress echo → high-risk; consider invasive angiography ^[139].
• Apical akinesis or aneurysm → look carefully for LV thrombus, use contrast ^[140].
• Wall-motion pattern beyond one coronary territory with apical ballooning → consider takotsubo ^[133].

Pitfalls & mimics

• Paradoxical septal motion LBBB, pacing, post-surgery and RV volume overload move the septum abnormally but it still thickens.
• Translation and tethering A normal segment next to an akinetic one may be dragged.
• Foreshortened apex Hides apical abnormalities.
• Attenuation Inferior and lateral walls can disappear in the far field ^[17].