A 68-year-old woman, a known hypertensive, presents 5 days after her first anterior MI with sudden syncope. On arrival she is unresponsive with a palpable carotid pulse rate of 40/min but no recordable blood pressure. ECG shows organized QRS complexes with no corresponding arterial pulsation on the monitor. Neck veins are distended. What is the most likely diagnosis?

• A Ventricular septal rupture
• B Left ventricular free wall rupture with haemopericardium ✓
• C Acute mitral regurgitation from papillary muscle rupture
• D Complete atrioventricular block

Explanation

Free wall rupture typically occurs 3 to 7 days after a first transmural infarct in elderly hypertensive patients, especially women. It presents as abrupt pulseless electrical activity with distended neck veins from tamponade, unlike septal rupture or papillary muscle rupture, which produce murmurs and shock but preserved mechanical contraction. Emergent pericardiocentesis and surgical repair are required; mortality is very high without immediate intervention.

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

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Written and medically reviewed by the StethoPrep medical team.