A 62-year-old man presents with STEMI. Primary PCI is performed within 60 minutes. Post-PCI ECG shows >50% resolution of ST elevation. On day 2, he develops hypotension, elevated JVP, clear lung fields, and a new harsh pansystolic murmur at the left lower sternal border. What is the most likely diagnosis?
- A Ventricular septal rupture ✓
- B Acute mitral regurgitation due to papillary muscle rupture
- C Right ventricular infarction
- D Free wall rupture with tamponade
Explanation
Ventricular septal rupture (VSR) classically presents 3–5 days post-MI with a new harsh pansystolic murmur at the left sternal border, cardiogenic shock, elevated JVP, and clear lungs (step-up in oxygen saturation on right heart catheterisation confirms the diagnosis). Papillary muscle rupture causing acute MR presents with murmur best heard at apex radiating to axilla and prominent pulmonary oedema. RV infarction is characterised by hypotension, elevated JVP, and clear lungs but without this murmur. Free wall rupture typically causes sudden cardiac death with tamponade.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.