A 70-year-old woman develops cardiogenic shock 5 days after a large anterior STEMI. She becomes abruptly unresponsive with a palpable femoral pulse but no measurable blood pressure; the monitor shows organized wide complexes without a corresponding arterial waveform. Bedside echocardiography shows a moderate pericardial effusion with diastolic collapse of the right ventricle. What is the most likely diagnosis?

• A Ventricular septal rupture
• B Recurrent thrombotic occlusion of the stented LAD
• C Complete heart block with idioventricular rhythm
• D Left ventricular free wall rupture with hemopericardium ✓

Explanation

Free wall rupture occurs most often 1 to 7 days after a transmural MI, classically in elderly hypertensive women with a first infarct. Blood escapes into the pericardium causing tamponade, and the classic terminal event is pulseless electrical activity, exactly as described. Septal rupture produces a murmur and shock without effusion, complete heart block shows bradycardia rather than PEA, and reocclusion causes recurrent pain and ST changes.

Reference: Robbins and Cotran Pathologic Basis of Disease, 10th ed.

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Written and medically reviewed by the StethoPrep medical team.