Rupture of the left ventricular free wall occurs in a significant percentage of patients who die after acute transmural myocardial infarction and it is the third most common cause of death after cardiogenic shock and cardiac arrhythmias. If unrecognized, it usually results in the patient’s sudden death.


In an autopsy series of patients dying from cardiac rupture following myocardial infarction (Batts, 1990):

(1) 13 occurred during the first day after the infarction

(2) 58% occurred within 5 days

(3) 80% within 7 days


Risk factors for postinfarction left ventricular free wall rupture:

(1) age > 60 years

(2) female gender

(3) pre-existing hypertensions

(4) absence of left ventricular hypertrophy

(5) first myocardial infarction

(6) midventricular or lateral wall transmural infarction


Signs and symptoms preceding cardiac rupture may develop during the first week after the myocardial infarction:

(1) pericarditis (positional pleuritic chest pain, friction rub, left shoulder or scapular pain)

(2) repetitive emesis

(3) restlessness and agitation


Frequency of signs and symptoms:

(1) 100% of patients had at least one of the 3 findings

(2) 2 or 3 of these symptoms are seen in > 80% of patients with rupture.

(3) 2 or 3 of the symptoms are seen in 3% of patients without rupture.


Rupture is often preceded by:

(1) 1 or more episodes of abrupt, transient hypotension and bradycardia

(2) unexpected alterations of the T waves from the customary course, especially directional changes (persistently or prematurely positive deflections in the T wave soon after the infarct, indicating regional pericarditis)



• The expected pattern of T wave evolution depends on whether reperfusion exists.

• With no reperfusion the maximal T wave negativity should be <= 2 mm within 72 hours after the infarction.

• With reperfusion the maximal T wave negativity should be >= 3 mm within 48 hours after the infarction.


If these findings are present, bedside echocardiography is indicated.

(1) If fluid is present, guided pericardiocentesis should be performed.

(2) If the fluid is blood, then immediate surgery is indicated.


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