Electrocardiogram during cardiac ruture by myocardial infarction

In 100 patients with acute myocardial infarction the electrocardiogram was continuously registered during 72 hours. Nine patients died of ventricular rupture (eight of the left ventricular free wall and one of the ventricular septum). In eight cases death occurred while the electrocardiogram was being recorded. A specific pattern of electrocardiographic changes seems to occur during acute tamponade, i.e. slowing of sinus rhythm followed by nodal rhythm.     

急性心肌梗死并发心脏破裂危险因素分析

目的分析急性心肌梗死(AMI)并发心脏破裂的临床特点、危险因素及预后,并探讨临床防治措施。方法回顾性收集AMI患者1561例,其中发生心脏破裂患者21例为心脏破裂组,随机选取未发生心脏破裂的AMI患者105例为对照组,采集2组患者临床资料及治疗方案,分析AMI并发心脏破裂的危险因素。结果与对照组比较,心脏破裂组年龄、入院心率、女性、肌钙蛋白、N末端B型钠尿肽前体、尿素明显升高(P<0.05,P<0.01),急诊PCI、血红蛋白、红细胞计数、使用β受体阻滞剂及血管紧张素转换酶抑制剂(ACEI)/血管紧张素受体阻滞剂(ARB)比例明显降低,差异有统计学意义[42.86%vs 72.38%,P=0.011;(119.33±19.37)g/L vs (139.29±17.65)g/L,P=0.001;(4.13±0.62)×10^12/L vs (4.60±0.69)×10^12/L,P=0.010;47.62%vs 73.33%,P=0.020;23.81%vs 52.38%,P=0.017]。结论女性、高龄、再灌注时间延迟、入院心率快、高NT-ProBNP、高肌钙蛋白、低血红蛋白、低红细胞计数是AMI患者心脏破裂的危险因素,早期的再灌注治疗、ACEI/ARB、β受体阻滞剂的使用是预防AMI后发生心脏破裂的重要措施。     

Brain natriuretic peptide and cardiac rupture after acute myocardial infarction

Cardiac rupture is a fatal complication in the acute stage of myocardial infarction (MI). However, no measures have yet been established to predict it. Herein we describe three MI patients with cardiac rupture in whom plasma brain natriuretic peptide (BNP) and atrial natriuretic peptide (ANP) concentrations had been serially monitored from the onset of MI to cardiac rupture. In these cases, plasma BNP levels increased without symptomatic and hemodynamic changes and reached their highest level immediately before cardiac rupture, while plasma ANP levels remained unchanged. These cases suggest that the increased plasma BNP concentrations without symptomatic and hemodynamic changes may be a useful marker for predicting cardiac rupture after acute MI.     

Developing cardiac rupture as initial sign of acute myocardial infarction.

Pathological data are given of 4 patients in whom the development of cardiac rupture was the initial sign of myocardial infarction. The term ''concealed cardiac rupture'' is proposed for this condition. In each instance the clinical diagnosis was ''onset of infarction'', whereas the necropsy suggested that the acute onset of symptoms was caused by the start of rupture. The arguments for classifying the cases as ''concealed rupture'' are (1) the lack of correlation between histological and clinical dating of the infarct, (2) the observation that the tear may take considerable time before actual epicardial breakthrough occurs, and (3) the fact that a high percentage of infarcts may pass clinically unnoticed.     

Clinical and electrocardiographic features of cardiac rupture following acute myocardial infarction

Characteristic clinical and electrocardiographic findings are reported in six autopsy cases of cardiac rupture following acute myocardial infarction. These patients were generally elderly with an acute, transmural myocardial infarction uncomplicated by “pump failure.” They had hypertension and/or a “stressful episode” prior to cardiac rupture. Delay in diagnosis of myocardial infarction, absence of previous history of coronary artery disease and new or protracted chest pain were frequent accompanying findings. At the time of cardiac rupture the electrocardiogram showed persistent electrical activity when apparent mechanical activity was absent (electromechanical dissociation), preceded or accompanied by S-T segment elevation or depression.     

Cardiac rupture complicating myocardial infarction

Rupture of the ventricular free wall is a leading cause of death in patients with acute myocardial infarction (MI). There are a number of risk indicators that are associated with cardiac rupture, such as female gender, old age, hypertension, and first MI. Typical symptoms of cardiac rupture are recurrent or persistent chest pain, syncope, and distension of jugular veins. Electrocardiographic signs may include sinus tachycardia, new Q-waves in 2 or more leads, persistent or recurrent ST segment elevation, deviation of expected evolutionary T-wave pattern, and electromechanical dissociation in end-stage cases. Once patients at risk have been identified using clinical symptoms and electrocardiographic signs, a fast and sensitive diagnostic test to confirm cardiac rupture is transthoracic echocardiography (TTE). New insights in the etiology of subacute myocardial rupture suggests that defective cardiac remodeling may predispose the heart for rupture. The matrix metalloproteinase (MMP) system has been shown to play an important role in cardiac extracellular matrix (ECM) remodeling and cardiac rupture. Current therapy of cardiac rupture consists mainly of surgery, and conservative management with hemodynamic monitoring, prolonged bed rest, beta-blockers, and angiotensin-converting enzyme (ACE) inhibitors in selected cases.     

Outcome after cardiac arrest during acute myocardial infarction

A community-wide study of acute myocardial infarction (AMI) was conducted in all 16 acute-care general hospitals in the Worcester, Massachusetts, metropolitan area during the years 1975, 1978, 1981 and 1984. The in-hospital and long-term prognoses of 667 patients with AMI complicated by cardiac arrest (CA) was compared with that of 2,596 AMI patients without CA. The incidence of CA complicating AMI was similar (21%) during each of the 4 study years. Among patients with AMI who had CA, 36% had CA within the first day of hospitalization and 48% within the first 2 days. The in-hospital case-fatality rate was much higher for AMI patients with CA (78%) than for those without CA (4%) (p less than 0.001). For patients discharged alive from the hospital, a trend toward a higher mortality rate was seen at 1 and 2 years after hospital discharge for patients with CA; however, long-term survival rates were not significantly different between AMI patients with and without CA. When time of occurrence of CA relative to in-hospital survival was examined, patients with early CA (within 1 day or within 2 days of hospital admission) had a significantly greater in-hospital survival (39% and 34%) than did those with late CA (after 1 day or after 2 days) (13% and 12%). Similarly, patients discharged from the hospital after early CA had a significantly better chance of long-term survival than patients discharged after late CA.     

Ventricular rupture during acute myocardial infarction (author's transl)]

In a series of 523 consecutive patients with acute myocardial infarction (AMI) 112 died; among these were 18 with rupture of the free wall of the left ventricle (HR) (group RU); two other cohorts were formed: one sample of all patients with acute (transmural) myocardial infarction (group KO) and another cohort of death of AMI in 1976 (EX). 1. patients with HR are significantly older than the KO group; there is no difference in age compared to the patients who died of AMI other than HR (group EX). 2. Women with AMI have a higher chance to die of HR than men. 3. The RU group has significantly more often clinical signs of congestive heart failure than the control group. 4. Cardiogenic shock is significantly more frequent in the RU-group than in the control group. 5. All deaths (EX + RU) have worse hemodynamic data than the control group (KO). 6. Elevated blood pressure (before and after AMI) could not be identified as a risk factor for HR in our patients. 7. In the course of AMI, death in pump failure occurs significantly later than heart rupture.     

急性心肌梗死后心脏破裂的诊治进展

心脏破裂是急性心肌梗死（AMI）的机械并发症之一,往往预后不良,同时也是心肌梗死患者的第二大死亡原因。心脏破裂由于其发病突然,病情恶化迅速,目前临床治疗手段有限,病死率高,因此识别AMI后心脏破裂的高危人群,建立精准的风险预测模型,早期诊断并进行评估,及时有效的治疗尤为重要。     

Tamponade without cardiac rupture after repetitive thrombolysis in acute myocardial infarction]

The authors report the case of tamponade without cardiac rupture 48 hours after a second course of intravenous thrombolytic therapy undertaken for unstable angina in laterobasal infarction in a 72 year old woman. The outcome after ultrasonic guided pericardiocentesis and surgical drainage (700 cc) was favourable. This is a rare complication of thrombolytic therapy (10 cases) and usually observed after anterior myocardial infarction.