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.

Another Heart Attack 2 ecg

Figure 2: Patient ECG


Another Heart Attack 3 ultrasound - left ventricular wall rupture

Figure 3: Patient bedside cardiac ultrasound with color Doppler

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

Troponin: 26.97 ng/mL

  • 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.

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

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.

Andrew Ortega, MD

Andrew Ortega, MD

Clinical Assistant Professor
Department of Emergency Medicine
Kaiser Permanente Central Valley
Andrew Ortega, MD

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Sara M. Krzyzaniak, MD, FACEP

Sara M. Krzyzaniak, MD, FACEP

ALiEM Faculty Incubator
Chief Operating Officer
Assistant Program Director, Emergency Medicine Residency
University of Illinois College of Medicine at Peoria
OSF Healthcare Saint Francis Medical Center
Sara M. Krzyzaniak, MD, FACEP

@SMKrzyz

EM doc, residency APD with interest in remediation best practices and curriculum development