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[Heart rupture during maximal exercise test before hospital discharge after acute myocardial infarction]
R Carlon1, L Pedon, P Maiolino
1Divisione Cardilogica, Ospedale Civile, Cittadella (PD).
Insights
A patient experienced electromechanical dissociation and cardiac rupture following a maximal exercise test 13 days after a myocardial infarction. This case highlights the risks of exercise testing post-heart attack.
Area of Science:
- Cardiology
- Internal Medicine
Background:
- A 64-year-old male underwent maximal exercise testing 13 days after an inferoposterior myocardial infarction without thrombolytic treatment.
- Pre-existing complete right bundle branch block and intermittent Mobitz heart block were noted prior to the stress test.
Observation:
- The patient tolerated the initial phase of the exercise test, with increased heart rate and blood pressure.
- Electrocardiogram (ECG) showed ST segment elevation in leads with pathological Q waves and ST depression in V1-V2 and aVL.
- During recovery, the patient developed electromechanical dissociation and significant pericardial effusion.
Findings:
- Maximal exercise testing in the subacute phase post-myocardial infarction can precipitate fatal complications.
- Left ventricular inferior wall rupture and hemopericardium were confirmed post-mortem.
Implications:
- This case underscores the critical importance of careful patient selection and risk stratification before exercise testing in post-myocardial infarction patients.
- The findings suggest that even in the absence of anginal pain or arrhythmias during the test, severe complications like cardiac rupture can occur.
Abstract:
A 64 years old patient performed a maximal exercise testing 13 days after inferoposterior myocardial infarction (no thrombolytic treatment had been performed). The patient presented at days 1-4 an intermittent Mobitz 1 and 2:1 heart block, with normal ventricular rate. No other complications were present. The ECG at entry and before stress test showed a complete right bundle block. The test was stopped at 30 sec of 75 watts. The systolic blood pressure increased from 130 to 155 mm Hg and heart rate from 84 to 145/min (93% of predicted heart rate). No arrhythmias and anginal pain were noted. The leads with pathologic Q wave showed elevation of the ST segment, whereas V1-V2 and aVL leads a depression of the ST segment. During recovery the patient developed electromechanical dissociation. The echocardiogram showed significant pericardial effusion. Cardiopulmonary resuscitation and pericardiocentesis were ineffective. Necropsy confirmed left ventricular inferior wall rupture and haemopericardium.