SAEM Clinical Image Series: Another Heart Attack?

[Figure 1: Click for larger view]

Chief Complaint: Chest pain

History of Present Illness: An 89-year-old female with a past medical history of coronary artery disease and with recent admission for myocardial infarction that was medically managed, presented with chest pain and shortness of breath. She reports worsening midsternal chest pain that occasionally radiates to her back and right arm since discharge.

Figure 2: Patient ECG

Another Heart Attack 3 ultrasound - left ventricular wall rupture

Figure 3: Patient bedside cardiac ultrasound with color Doppler

Physical Exam

The patient’s vitals signs and physical exam were unremarkable.

Laboratory Data

Troponin: 26.97 ng/mL

Case Question: What's the diagnosis?

Figure 1 shows a circumferential pericardial effusion.
The ECG (figure 2) shows a lateral myocardial infarction, which is likely the progression of her myocardial infarction that was medically managed previously.
Figure 3 image shows the free wall rupture with a “jet” of blood leaving the lateral wall using Color Doppler.

Case Question: What's the clinical significance on the bedside ultrasound?

It shows a left ventricular free wall rupture, a known but rare complication of acute myocardial infarction.

Case Answer/Discussion

Left ventricular free wall rupture happens in about 2% of all patients with acute myocardial infarction.

Rupture typically occurs about 3-5 days after infarction.

There are 3 classifications, Type I–III, which are dependent on the time of rupture from when the infarction occurred. Rupture occurs near the edge of where necrotic myocardium meets healthy myocardium. Treatment for left ventricular rupture is supportive with blood pressure management in the immediate setting. If the patient does survive acute rupture, surgical correction can be performed if feasible. Prognosis is dependent on multiple factors, but overall prognosis is poor with mortality near 100%.

This patient was diagnosed with left ventricular free wall rupture after bedside ultrasound was performed. The patient’s previous myocardial infarction happened four days prior to presentation. The patient survived her weeklong hospital stay and elected for medical management only. The patient was discharged home in stable condition.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2019 SAEM Annual Meeting | Copyrighted by SAEM 2019 – all rights reserved. View other other cases from this series on ALiEM.

Author information

Andrew Ortega, MD

Clinical Assistant Professor
Department of Emergency Medicine
Kaiser Permanente Central Valley

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