DIAGNOSIS OF SUBACUTE VENTRICULAR WALL RUPTURE AFTER ACUTE MYOCARDIAL-INFARCTION - SENSITIVITY AND SPECIFICITY OF CLINICAL, HEMODYNAMIC AND ECHOCARDIOGRAPHIC CRITERIA

When ventricular free wall rupture after acute myocardial infarction is not followed by sudden death, it is referred to as subacute ventricular rupture. The sensitivity and specificity of clinical, hemodynamic and echocardiographic diagnostic variables obtained at bedside are unknown and were therefore prospectively studied in 1,247 consecutive patients with acute myocardial infarction including 33 patients with subacute ventricular rupture diagnosed at operation (group A) and 1,214 patients without ventricular rupture (at operation, postmortem study or at discharge) (group B). The incidence of syncope, recurrent chest pain, hypotension, electromechanical dissociation, cardiac tamponade, pericardial effusion, high acoustic intrapericardial echoes, right atrial and right ventricular wall compression identified in two-dimensional echocardiograms and hemopericardium demonstrated during pericardiocentesis was higher in group A than in group B (p < 0.00001). The presence of cardiac tamponade, pericardial effusion > 5 mm, high density intrapericardial echoes or right atrial or right ventricular wall compression had a high diagnostic sensitivity (greater-than-or-equal-to 70%) and specificity (> 90%). The number of false positive diagnoses was always high for each diagnostic variable alone (> 20%), but the combination of clinical (hypotension), hemodynamic (cardiac tamponade) and echocardiographic variables allowed a sensitivity of greater-than-or-equal-to 65% with a small number of false positive diagnoses (< 10%) and provided useful information for therapeutic decisions. The diagnosis of subacute ventricular rupture requires a surgical decision. Twenty-five (76%) of the 33 patients with subacute ventricular rupture survived the surgical procedure and 16 (48.5%) are long-term survivors. Thus, subacute ventricular wall rupture is a relatively frequent complication after acute myocardial infarction that can be accurately diagnosed and successfully treated.