The cardiologist Aitor Jiménez has managed to gather and characterise in detail 110 cases of cardiac rupture (CR), after spending 22 years (1978-2000) gathering data at the Hospital de Cruces, near Bilbao. It is one of the broadest anatomical series described in this respect. CR is the most serious complication of acute myocardial infarction; it is not very common, but when it does occur, it is mortal in practically all cases. So prevention, although difficult, seems more feasible than cure. Thanks to Jiménez’s study, CR risk factors have been detected “to be able to partly predict this complication and conduct more exhaustive monitoring.” His thesis, which he defended at the University of the Basque Country (UPV/EHU), is entitled Rotura cardiaca en el infarto agudo de miocardio. Correlación clínica y patológica (Cardiac rupture in acute myocardial infarction. Clinical and pathological correlation).
In the cases in which CR occurs, it appears on average on the third day following the infarction. The infarcted wall tears, the blood rushes from the ventricular cavity into the pericardium. The latter cannot handle such a large quantity of blood, so it ends up compressing the heart and stopping it as a result of cardiac tamponade. The rate of CR only represents 1.5% of all the cases studied by Jiménez. However, if one looks only at the patients who end up dying following the infarction, CR turns out to be the cause of death in 29% of the cases.
The onset of this complication is, as Jiménez explains, sudden: “Once it takes place, the patient dies in 20 minutes. You diagnose it, but there’s virtually nothing you can do. At the Hospital de Cruces, a very aggressive protocol has even been established. If CR is suspected, open the patient’s thorax in situ and try to plug the hole with your finger. Not even that way can you save the majority of patients with acute breach.” In the cases of subacute breach, the patient survives for at least an hour, but even though on occasions there is time to operate, the survival outcomes are few and far between. In Jiménez’ study there is a record of one case of survival following acute breach and two or three in the case of subacute. These data show that acting quickly is not effective enough. The thesis focuses on acting in advance; to learn to read the warning signs in order to react before CR occurs.
These signs indicate that CR more frequently affects the elderly, women, patients with a history of arterial hypertension and without a history of diabetes, heart failure or ischemic heart disease (angina or heart attack).
One of the main risk factors is delay in getting to hospital: even though in terms of symptoms and pain the heart attack that leads to CR is the same as any other attack, whatever the reason may be, these patients get to A&E later. “Because the symptoms are minimized or because they are attributed to something else… What happens is that in the few cases in which the patients have a heart attack, they get through it and arrive when clinical pericarditis has set in (about 24 hours following the attack), they have a very high rate of breach,” explains Jiménez. He also highlights the fact that the heart attack that ends in CR evolves in a more benign way than usual: “Its evolution is less complicated, it is a milder attack.”
So the results of the thesis point to monitoring heart attack patients more when they get to hospital late, particularly if they are women and/or elderly women. Jiménez mentions another detail: “It only happens in a third of the cases, but it is important to observe during the course of the attack whether the patient is uneasy, has an unexplained sensation of discomfort and which cannot be attributed to pain or if he or she is suffering from nausea. Having a great tendency to vomit after 24 hours (in the first few hours is normal) is one of the factors associated with CR.” In these cases, the researcher believes that they need to be strict when applying preventive drugs (ACE inhibitors, betablockers, etc.) and also need to do more intensive echocardiographic monitoring.
These measures are already being taken at the Hospital de Cruces, but Jiménez warns that at the present time their effectiveness cannot be proven either. “There is nothing that says that a breach is going to be prevented. There aren't many studies; it is a disease with a low incidence, with such a high mortality rate and which cannot be anticipated... But if you know which cases are more likely to be exposed to this complication, it is important to provide closer monitoring.”