Two-dimensional echocardiography at rest was used to analyze segmental wall motion abnormalities for detecting coronary artery disease in patients with and without a history of myocardial infarction. One hundred twenty-five echocardiograms were analyzed in a randomized, blinded fashion. They were obtained from 55 consecutive patients found to have significant coronary artery disease at angiography, 59 consecutive normal subjects and 11 patients with dilated cardiomyopathy. The overall sensitivity of two-dimensional echocardiography was relatively low at 67%. However, specificity was 99%. The sensitivity was higher in patients with past myocardial infarction than in those without myocardial infarction (81 versus 42%), as expected. Echocardiography can detect segmental wall motion abnormalities in some patients with coronary artery disease and no overt prior myocardial infarction. This was highlighted by nine such patients with coronary artery disease and no prior myocardial infarction or electrocardiographic Q waves who were found to have segmental wall motion abnormalities. A semiquantitative, two-dimensional echocardiographic segmental wall motion score was derived for 47 patients and was correlated with angiographic left ventricular ejection fraction (r = 0.71). This score differentiated patients with a normal ejection fraction (greater than 50%) from those with a depressed ejection fraction (less than 50%): 1.1 +/- 1.6 versus 6.9 +/- 3.1 (p less than 0.001). Almost all patients (92%) with an echocardiographic score of five or more had an abnormal ejection fraction of less than 50%. In patients with chronic congestive heart failure, the echocardiogram separated those with dilated cardiomyopathy from those with coronary artery disease.(ABSTRACT TRUNCATED AT 250 WORDS)