Free-wall rupture of the myocardium following infarction: a changing clinical portrait in the reperfusion era: a case report.

Free wall rupture of the myocardium is an important complication and major cause of death following acute transmural (ST segment elevation) myocardial infarction. Pathologic changes on a cellular level may combine with mechanical stressors to weaken the myocardium postinfarction. Risk factors for myocardial rupture include advanced age, female gender, prior hyper-tension, first myocardial infarction, late presentation, lack of collateral blood flow, and persisting chest pain and ST segment elevations. Thrombolytic therapy does not increase risk of rupture when given early in myocardial infarction, but late thrombolytic therapy may heighten risk. Primary percutaneous coronary intervention for acute myocardial infarction has reduced the incidence of myocardial rupture compared to thrombolytic therapy. This advantage likely can be ascribed to higher rates of immediate reperfusion with catheter techniques, as well as to the avoidance of thrombolytic-mediated hemorrhagic transformation of the infarction zone. Careful regulation of blood pressure and pulse using nitrates and beta-adrenergic blockers may mitigate the tendency toward myocardial rupture. Early and accurate diagnosis based on clinical and echocardiographic evidence can lead to successful surgical treatment.