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Case 2

Image: transverse slice of the heart

This is a transverse slice of the heart of a patient who presented with crushing central chest pain and ST elevation on the electrocardiogram. An ST elevation myocardial infarction was diagnosed and the patient was treated with aspirin and streptokinase and transferred to the coronary care unit. Three days later he became suddenly unwell with severe breathlessness, hypotension, and a new loud pansystolic murmur. Despite active treatment, he died. A post-mortem examination was performed and the principal findings were a large anteroseptal acute myocardial infarction, fresh thrombus in the left main stem coronary artery, and a ruptured interventricular septum (image).

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Question 1

Which of the following statements are true regarding ruptured interventricular septum? (Tick all those that apply)

a)
b)
c)
d)

Correct. Rupture of the interventricular septum following acute myocardial infarction causes an acquired ventricular septal defect. Acute heart failure occurs due to a massive left-to-right shunt. Rupture typically occurs 3-5 days post-infarction when the necrotic myocardium is at its softest. Rupture of the free wall of the left ventricle causes haemopericardium and rapid death due to cardiac tamponade.

Incorrect. Rupture of the interventricular septum following acute myocardial infarction causes an acquired ventricular septal defect. Acute heart failure occurs due to a massive left-to-right shunt. Rupture typically occurs 3-5 days post-infarction when the necrotic myocardium is at its softest. Rupture of the free wall of the left ventricle causes haemopericardium and rapid death due to cardiac tamponade.

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2
Question 2

Which of the following statements are true regarding complications of acute myocardial infarction? (Tick all those that apply)

a)
b)
c)
d)

Correct. Most cases of ventricular tachycardia following myocardial infarction are self-limiting and do not cause haemodynamic compromise. Thrombus often forms on the endocardial surface of an akinetic segment of infarcted myocardium; if this embolizes into the systemic circulation then this may cause stroke due to cerebral infarction. Myocardial infarction is the commonest cause of acute pericarditis, which may cause a dull central chest pain 1-3 days after the infarct. Ventricular aneurysm is a long term complication of myocardial infarction which develops in about 10% of patients; persistent ST elevation on the electrocardiogram is a well recognized feature.

Incorrect. Most cases of ventricular tachycardia following myocardial infarction are self-limiting and do not cause haemodynamic compromise. Thrombus often forms on the endocardial surface of an akinetic segment of infarcted myocardium; if this embolizes into the systemic circulation then this may cause stroke due to cerebral infarction. Myocardial infarction is the commonest cause of acute pericarditis, which may cause a dull central chest pain 1-3 days after the infarct. Ventricular aneurysm is a long term complication of myocardial infarction which develops in about 10% of patients; persistent ST elevation on the electrocardiogram is a well recognized feature.

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3
Question 3

Which of the following statements about thrombosis are true? (Tick all those that apply)

a)
b)
c)
d)

Correct. Thrombosis may occur anywhere in the circulatory system, including capillaries. The risk factors for thrombosis are changes in the vessel wall, changes in blood flow, and changes in blood coagulability - collectively known as Virchow's triad. Arterial thrombosis is usually related to a complicated unstable atherosclerotic plaque. The main risk with venous thrombosis is thromboembolism.

Page references for entire case study: 65-68, 90-92

Incorrect. Thrombosis may occur anywhere in the circulatory system, including capillaries. The risk factors for thrombosis are changes in the vessel wall, changes in blood flow, and changes in blood coagulability - collectively known as Virchow's triad. Arterial thrombosis is usually related to a complicated unstable atherosclerotic plaque. The main risk with venous thrombosis is thromboembolism.

Page references for entire case study: 65-68, 90-92

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