Acute Care Echo

The short-axis sweep in acute chest pain

A patient with chest pain, and a parasternal short-axis sweep from base to apex. What the sweep can tell you, and what it cannot.

Chest pain on the acute take. You sweep the parasternal short axis from base to apex. Regional, global, or normal?

Make your call before you reveal the answer.

A regional wall motion abnormality. The anterior and anteroseptal walls fail to thicken while the inferior and lateral walls thicken normally, which fits the usual left anterior descending (LAD) territory.

On the sweep from base to apex, the anterior and anteroseptal walls show reduced systolic thickening while the neighbouring inferior and lateral walls thicken normally. That difference between neighbouring walls is what makes it regional.

Echo names the territory, not the timing. A regional wall motion abnormality does not date the injury. At British Society of Echocardiography (BSE) Level 1 we describe the abnormality and its territory; we do not date it. Wall thinning and increased echogenicity suggest established scar, but weighing those features sits beyond this focused level. Interpret it alongside the presentation, the electrocardiogram and troponin, and compare with previous imaging when available.

Pearls

Regional is reduced systolic thickening in a localised area. Global is reduced thickening throughout. Normal is preserved systolic thickening throughout the visible walls. Compare walls and levels, and judge thickening rather than movement alone.
Sweep from base to apex. A regional abnormality present at one level can be absent at another, so the sweep is the examination rather than an optional extra. Before calling a wall abnormal, check it is clearly seen in a true short-axis cut and confirm the finding in another view.
Start localisation at the basal and mid levels, then follow the pattern to the apex. Report the likely territory without forcing a single-artery label when the pattern is uncertain.

Pitfalls

Do not label a regional wall motion abnormality new or acute on the image alone.
A normal sweep does not exclude acute coronary syndrome. Continue the chest-pain assessment; a repeat echo is not a substitute for it and must not delay urgent care.
Global hypokinesis does not exclude an ischaemic cause. Severe multivessel coronary disease can present as global impairment.

Echo names the territory, not the timing. A regional wall motion abnormality does not date the injury, and a normal study does not exclude acute coronary syndrome.

Echo is one input to the assessment of chest pain. It does not admit the patient and it does not discharge them.

BSE Level 1 assessment is qualitative and describes regional wall motion by territory rather than by numbered segment. This recognises the presence or absence of a regional wall motion abnormality and assigns its likely territory. It does not date the injury, establish the aetiology, grade severity or exclude acute coronary syndrome. Poor windows, foreshortening and off-axis imaging all reduce confidence. A short-axis sweep is one part of the focused examination; if a wall is not adequately seen, optimise or seek further imaging rather than calling it normal.

This is one call from the Acute Echo Trainer. Module 05 works the short-axis sweep in three steps: separate regional from global and from normal, assign the territory, then decide safely when the sweep looks normal and the pain has not settled.

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Dr Mansour

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This content is for educational purposes for healthcare professionals and does not replace supervised clinical training or local governance.