Myocardial Infarction: clinical haemodynamic and echocardiographic criteria helped to diagnose subacute ventricular wall rupture.

Clinical bottom line (level 4)

  1. In patients with acute myocardial infarction, pericardial effusion >5 mm and haemopericardium rule out subacute ventricular wall rupture in those with negative results (SnNOut - Sensitivity 100%)
  2. In patients who have had an MI, hypotension, intrapericardial echoes, right atrial wall compression, and pericardial effusion plus intrapericardial echoes helped to rule out subacute ventricular wall rupture in those with negative results.
  3. Hypotension, cardiac tamponade, pericardial effusion >5 mm, intrapericardial echoes, wall compression, electromechanical dissociation, pericardial effusion plus intrapericardial echoes and/or wall compression, and tamponade plus pericardial effusion and/or wall compression helped to rule in subacute ventricular wall rupture.
Lopez-Sendon et al: Journal of the American College of Cardiology 1992; 19: 1145-1153
Expires March 2003

The study

Setting: coronary care unit of a general hospital, Spain

1457 patients (aged mean 64 years, 83% male) acute myocardial infarction defined by common clinical. electrocardiographic and laboratory data

Excluded if
  • previous heart surgery
  • valvular heart disease
  • primary myocardial or pericardial disease
  • insufficient echocardiographic data
  • died without anatomic examination
  • heart rupture demonstrated at post mortem



    • Non-independent ?blinded reference standard, applied in all patients from a consecutive inappropriate spectrum.
    Reference standard:
    • known diagnosis after surgery or autopsy, or 1 year follow-up without symptoms or echo evidence
    Diagnostic test: clinical, haemodynamic and echocardiographic criteria

    The evidence

    pre-test probability of ventricular rupture: 2.6%, (95% CI: 1.8% to 3.7%)

    diagnostic test number of patients sensitivity for
    subacute ventricular wall rupture
    (95% CI)    		 specificity for
    subacute ventricular wall rupture
    (95% CI)    		 LR+ LR-
    hypotension- systolic blood pressure <90 mmHg in previously normotensive patients and <100 mmHg in hypertensive patients 31 93.9%
    (% to %)     		81.5%
    (% to %)     		11.0 0.07
    cardiac tamponade 23 69.7%
    (% to %)     		99.5%
    (% to %)     		140 0.30
    pericardial effusion >5 mm 33 100%
    (% to %)     		92.8%
    (% to %)     		13.9 0.00
    intrapericardial echoes 32 97.0%
    (% to %)     		92.8%
    (% to %)     		13.5 0.03
    right atrial wall compression 32 97.0%
    (% to %)     		98.3%
    (% to %)     		57.0 0.03
    electromechanical dissociation 7 21.2%
    (% to %)     		99.7%
    (% to %)     		70.7 0.79
    haemopericardium (pericardiocentesis) 13 100%
    (% to %)     		76.9%
    (% to %)     		4.3 0.00
    pericardial effusion plus intrapericardial echoes 32 97.0%
    (% to %)     		98.4%
    (% to %)     		57.0 0.03
    pericardial effusion >5 mm plus intrapericardial echoes plus right atrial wall compression 31 93.9%
    (% to %)     		99.3%
    (% to %)     		134 0.06
    pericardial effusion >5 mm plus intrapericardial echoes plus right atrial wall compression plus right ventricular wall compression 30 84.8%
    (% to %)     		99.6%
    (% to %)     		212 0.15
    tamponade plus pericardial effusion >5 mm 23 69.7%
    (% to %)     		99.8%
    (% to %)     		348 0.30
    total 33

    • Adding intrapericardial echoes and right atrial or ventricular wall compression to tamponade plus pericardial effusion, made no difference to the sensitivity and specificity of these clinical features in diagnosing ventricular wall rupture.

    Comments

    1. The unusual exclusion criteria and mixed bag of reference standards mean this is difficult to be certain about.

    Citation

    1. Lopez-Sendon J, Gonzalez A, Lopez E, et al: Diagnosis of subacute ventricular wall rupture after acute myocardial infarction: sensitivity and specificity of clinical, hemodynamic and echocardiographic criteria. Journal of the American College of Cardiology 1992; 19: 1145-1153
    Contributor: Clare Wotton and Bob Phillips, December 1999
    Reviewer:

    Clinical Question.
    Patient acute myocardial infarction
    Intervention or Exposure clinical, haemodynamic and echocardiographic criteria
    Outcome diagnosis of subacute ventricular wall rupture