A 60-year-old man dies 4 days after an acute anterior STEMI. At autopsy, the infarcted myocardium shows yellow-gray softening with a hyperemic border. Histologically, there is coagulative necrosis with abundant neutrophil infiltration. Which complication is MOST feared at this stage?

• A Dressler syndrome — autoimmune pericarditis typically at 2–10 weeks post-MI
• B Ventricular free wall rupture — peak risk 3–7 days post-MI during neutrophilic enzymatic digestion ✓
• C Ventricular aneurysm — fibrotic remodeling over weeks to months
• D Mural thrombus formation — requires endocardial fibrosis underlying the akinetic segment

Explanation

Ventricular free wall rupture peaks at 3–7 days post-MI when neutrophilic enzymatic digestion of the necrotic myocardium maximally weakens the wall. Macrophages replace neutrophils by day 7–10, and fibrotic replacement begins around 2 weeks. Dressler syndrome occurs 2–10 weeks later due to autoimmune pericarditis. Ventricular aneurysm results from completed fibrotic remodeling over weeks to months. Mural thrombus forms on the exposed endocardium over akinetic myocardium and is a risk throughout the acute and subacute period.

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

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Written and medically reviewed by the StethoPrep medical team.