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[Heart rupture during pre-discharge stress test after myocardial infarction]
F Casazza1, A Capozi, A Bongarzoni
1Divisione di Cardiologia, Azienda Ospedaliera San Carlo Borromeo, Milano. fcasazza@tin.it
Insights
A patient with myocardial infarction died during exercise testing due to cardiac arrest from hemopericardium. This highlights the unpredictable risks of pre-discharge exercise tests in post-MI patients.
Area of Science:
- Cardiology
- Clinical Medicine
Background:
- A 65-year-old male presented with postero-lateral myocardial infarction and rapid atrial fibrillation.
- Treatment included thrombolysis and i.v. amiodarone for rhythm conversion.
Observation:
- Echocardiograms showed postero-lateral hypokinesis and reduced left ventricular ejection fraction.
- On day 7, post-pharmacological wash-out, a bicycle exercise test precipitated cardiac arrest.
Findings:
- The patient experienced electromechanical dissociation and hemopericardium, leading to cardiac arrest.
- Autopsy revealed a large pericardial clot and two tears in the left ventricular lateral wall.
Implications:
- This case underscores the potential for unpredictable, fatal complications during pre-discharge exercise testing in myocardial infarction survivors.
- Careful patient selection and informed consent regarding exercise test risks are crucial for clinical decision-making.
Abstract:
A 65-year-old man with a postero-lateral myocardial infarction, complicated by rapid atrial fibrillation was admitted to the Intensive Coronary Care Unit. He received thrombolytic treatment. Electrocardiography and laboratory analysis were suggestive of reperfusion; the rapid atrial fibrillation was converted to sinus rhythm using i.v. amiodarone. Two echocardiograms performed on days 1 and 6 revealed hypokinesis of the postero-lateral wall and a mild reduction in the left ventricular ejection fraction. On day 7, after pharmacological wash-out, he was submitted to a bicycle exercise test: soon after the beginning of the 75 W step, the patient presented cardiac arrest due to electromechanical dissociation and hemopericardium. Despite prolonged cardiopulmonary resuscitation maneuvers and drainage of a few milliliters of pericardial blood, the patient did not survive. At autopsy, a huge clot filling the pericardial space was detected together with two linear 3 cm tears of the left ventricular lateral wall. The authors stress the possibility of unpredictable deaths during a pre-discharge exercise testing; good clinical judgment should therefore be used in deciding which patients should undergo this procedure and appropriate information about its potential risks should be given.