A 58-year-old diabetic man presents 90 minutes after onset of crushing chest pain. ECG shows ST elevation in V2-V5. He is taken for primary PCI. On opening the LAD, a large thrombus burden is found with TIMI 0 flow. After aspiration thrombectomy and stent placement, TIMI 3 flow is restored but the patient develops acute hypotension and raised JVP 40 minutes later. Bedside echo shows RV dilatation with septal D-sign and moderate pericardial effusion. The MOST likely diagnosis is:
- A Right ventricular infarction with acute cor pulmonale ✓
- B Left ventricular free wall rupture
- C Ventricular septal defect (post-MI VSD)
- D Papillary muscle rupture causing acute mitral regurgitation
Explanation
ST elevation in V2-V5 reflects LAD territory, but right-sided involvement can occur if there is proximal LAD obstruction affecting right ventricular branches or concomitant RCA disease. The classic triad of RV infarction is hypotension, raised JVP, and clear lung fields. Echocardiographic D-sign (septal flattening due to interventricular dependence) and RV dilatation confirm RV infarction. LV free wall rupture would cause tamponade with progressively falling BP and Beck's triad; pericardial effusion may be present but the pattern of raised JVP with RV dilatation points to RV infarction. Papillary muscle rupture causes acute pulmonary oedema with flash APO.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.