Question:hard
Ramkumar, a 70 year old hypertensive male, was admitted to the intensive care unit with transmural anterolateral myocardial infarction. His condition was stable till the 5th day of admission, when he developed a pericardial friction rub and pleuritic chest pain which persisted despite narcotic and steroid therapy. On the 7th morning he suddenly developed marked hypotension. On examination, there was distension of jugular veins, accompanied by electromechanical dissociation. Most likely, the patient had developed:
Ramkumar, a 70 year old hypertensive male, was admitted to the intensive care unit with transmural anterolateral myocardial infarction. His condition was stable till the 5th day of admission, when he developed a pericardial friction rub and pleuritic chest pain which persisted despite narcotic and steroid therapy. On the 7th morning he suddenly developed marked hypotension. On examination, there was distension of jugular veins, accompanied by electromechanical dissociation. Most likely, the patient had developed:
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Pericarditis after a transmural MI followed by sudden hypotension, distended neck veins, and electromechanical dissociation on day 5 to 7 points to free wall cardiac rupture with tamponade.
Updated On: Jul 8, 2026
- Severe acute mitral regurgitation
- Ventricular septal rupture
- Right ventricular rupture
- External (free wall) cardiac rupture
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The Correct Option is D
Solution and Explanation
Step 1: Build the timeline of this patient.
A large anterolateral transmural infarct in an elderly hypertensive man is a known setup for the heart wall to give way. His course stayed stable for several days, then pericarditis appeared on day 5, and sudden collapse followed on day 7. Free wall rupture almost always shows up in this same first week window.
Step 2: Treat the pericarditis as a clue, not a coincidence.
A friction rub and persistent pleuritic pain over a dead area of heart muscle often signals that the wall there has become thin and fragile, which is exactly the setting in which the wall can tear open.
Step 3: Match the collapse to a mechanism.
Sudden low blood pressure, full neck veins, and a heart that keeps its electrical rhythm without pumping effectively is the signature of blood suddenly flooding the pericardial sac and squeezing the heart from outside, that is, tamponade from a torn free wall.
Step 4: Eliminate the other mechanical complications.
A torn papillary muscle gives a new murmur with flash pulmonary edema, not this tamponade picture. A torn septum gives a new pansystolic murmur and a shunt, again not this exact tamponade and electromechanical dissociation combination. Right ventricular rupture alone does not fit the anterolateral distribution or the typical week-one free wall rupture pattern as well as left ventricular free wall rupture does.
Step 5: Conclude.
$\boxed{\text{External (free wall) cardiac rupture}}$
A large anterolateral transmural infarct in an elderly hypertensive man is a known setup for the heart wall to give way. His course stayed stable for several days, then pericarditis appeared on day 5, and sudden collapse followed on day 7. Free wall rupture almost always shows up in this same first week window.
Step 2: Treat the pericarditis as a clue, not a coincidence.
A friction rub and persistent pleuritic pain over a dead area of heart muscle often signals that the wall there has become thin and fragile, which is exactly the setting in which the wall can tear open.
Step 3: Match the collapse to a mechanism.
Sudden low blood pressure, full neck veins, and a heart that keeps its electrical rhythm without pumping effectively is the signature of blood suddenly flooding the pericardial sac and squeezing the heart from outside, that is, tamponade from a torn free wall.
Step 4: Eliminate the other mechanical complications.
A torn papillary muscle gives a new murmur with flash pulmonary edema, not this tamponade picture. A torn septum gives a new pansystolic murmur and a shunt, again not this exact tamponade and electromechanical dissociation combination. Right ventricular rupture alone does not fit the anterolateral distribution or the typical week-one free wall rupture pattern as well as left ventricular free wall rupture does.
Step 5: Conclude.
$\boxed{\text{External (free wall) cardiac rupture}}$
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