Letter to the Editor Cardiac rupture during exercise test in post-myocardial infarction patients: A case report and brief review of the literature Alfonso Sestito, Maria Lucia Narducci, Gregory Angelo Sgueglia, Fabio Infusino, Gaetano Antonio Lanza * , Filippo Crea Institute of Cardiology, Universita ` Cattolica del Sacro Cuore, L. go A. Gemelli 8, Rome 00168, Italy Received 29 October 2003; received in revised form 25 November 2003; accepted 25 December 2003 Available online 2 April 2004 Keywords: Cardiac rupture; Post-myocardial infarction patients; Exercise test 1. Introduction Exercise stress test early after acute myocardial infarction has become common clinical practice for risk stratification of postinfarction patients [1]. However, although exercise test is generally a safe procedure, it has a small risk of life- threatening complications [2]. Cardiac rupture is a dramatic complication of acute myocardial infarction and it has rarely been reported to occur during early exercise test in post- infarction period. In this report, we describe a patient who developed cardiac rupture during exercise test early after acute myocardial infarction and who survived following a timely diagnosis by echocardiography and emergency sur- gical repair. 2. Case report A 71-year-old woman, smoker, without previous cardiac symptoms, was admitted to our Coronary Care Unit 4 h after the onset of a typical retrosternal chest pain. The electro- cardiogram (ECG) showed 2 mm ST-segment elevation in inferior leads. The patient was treated with accelerated rtPA (overall 100 mg IV in 1.5 h), aspirin (160 mg PO) and enoxaparin (1 mg/kg SC bid). In the next days, the patient was asymptomatic. On the fifth day after acute myocardial infarction, the patient underwent a treadmill exercise stress test using a modified Bruce protocol. After the beginning of the third stage (4 METs), ST-segment elevation in infero- lateral leads appeared suddenly on the ECG in the absence of any symptom. The exercise was stopped immediately, but the patient lost consciousness within a few second. She developed sinus bradycardia (40 bpm) with no appreciable peripheral pulse, pronounced jugular venous distension and subsequent respiratory arrest. Cardiopulmonary resuscita- tion was started and the patient rapidly recovered conscious- ness. However, blood pressure remained low (70/40 mm Hg) and IV dopamine (5 Ag/kg/min) and fluid administra- tion were started. Immediate 2D-echocardiography revealed an infero-lateral pericardial effusion that was up to 3 cm wide and included areas with high acoustic density echoes (Fig. 1), suggesting an acute cardiac rupture patched by 0167-5273/$ - see front matter D 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2003.12.031 * Corresponding author. Tel.: +39 6 3015 4187; fax: +39 6 3055 535. E-mail address: g.a.lanza@inwind.it (G.A. Lanza). www.elsevier.com/locate/ijcard Fig. 1. Transthoracic echocardiogram in subcostal view showing a relevant and diffuse pericardial effusion. Intrapericardial echodensities suggest blood clots. International Journal of Cardiology 99 (2005) 489 – 491