Acta Med Scand 205: 11-16, 1979
Cardiac Rupture in Acute Myocardial Infarction A Review of 72 Consecutive Cases Sten Rasmussen, Arne Leth, Erik Kjsller and Asger Pedersen From the Department of Cardiology, Copenhagen County Hospital, Glosrrup, Denmark
ABSTRACT. The occurrence of rupture of the external cardiac wall (CR) in a consecutive series of 2 244 admissions with confirmed acute myocardial infarction (AMI) has been analysed. The series comprises the unselected admissions to a single department, evaluated according to uniform criteria, with postmortem examination in 95 % of fatal cases. The incidence of CR was 3.2% af all cases of AMI, and 12.6% of all deaths. CR was significantly more frequent in women than in men, and in both sexes significantly more frequent after the age of 60, though the age distribution did not differ significantly from that of the patients dying from other causes. Moreover, CR was significantly more frequent in anterior wall infarctions, and in patients with no previous AMI. The majority of CR (84%) occurred within the first week, and a considerable part (32 %) within the first 24 hours after the onset of infarction. According to findings at autopsy, CR was accompanied particularly often (in 71 %) by complete occlusion of a major coronary artery. Autopsy findings gave no evidence that attempts at resuscitation, including external cardiac massage (65 patients), as well as intracardial injections (55 patients) and transthoracic introduction of a pace catheter (3 patients), could have any connection with the development of CR. The usual strict immobilization of the patients was applied during the first part of the series, but in the latter half (1 337 admissions) the patients were allowed to be out of bed from the first day with no imposed immobilization at all. The incidence of CR did not change significantly throughout the period, and the indication for maintaining the traditional immobilization of patients with AM1 is questioned. Key words: cardiac rupture, acute myocardial infarction, physical activity. Acta Med Scand 205: 1 I , 1979.
Myocardial rupture (CR) is a well known and almost invariably fatal complication to acute myocardial infarction (AMI) ( I ) . Physical activity in patients with fresh infarction has been suspected as
a precipitating factor, and this assumption has been
the major reason for the traditional prescription to these patients of a period of strict bed rest followed by gradual mobilization and gradual return to work. In this paper the incidence of rupture of the free wall and the hospital lethality have been followed in a large consecutive series of patients with AM1 treated with and without strict bed rest and immobilization during the acute phase. PATIENTS AND METHODS The report is based on a consecutive series of patients with AM1 admitted to a medical department during the years 1959-73, and from 1%6 to the Coronary Care Unit (CCU), of Copenhagen County Hospital, Glostrup. The hospital serves a well defined area from which all cases of suspected AM1 care are admitted without any preselection in relation to age or complicating diseases. This 14-year period can be divided into four stages, representing development from the non-monitored general medical ward with the traditional coronary regime to the full-time monitored CCU without immobilization of the patients. Period A . From 1959 to 1966 a general medical ward without ECG monitoring. All patients with AM1 were prescribed strict bed rest for up to eight days followed by gradual mobilization and discharge after four weeks. Period B . In the following two years patients with AM1 were monitored in a CCU for an initial period averaging three days, and were then transferred to a general medical ward. During their stay in the CCU they had some liberty to move around; but after transfer to the medical ward the traditional regime of immobilization was followed. Period C+D. During the subsequent four years the CCU was enlarged, so that patients with confirmed AM1 were now kept for the whole period of admission, i.e. for surviving patients at least 21 days after AMI. From 1968 to 1970 (period C) the patients were monitored for an average of five days. From 1971 to 1973 (period D) and later, the Reprint requests to: A. Pedersen, M.D., Cardiological Department, Copenhagen County Hospital, DK-2600 Glostrup, Denmark. Abbreviations: CR=myocardial rupture, AMI=acute myocardial infarction, CCU =coronary care unit. Acta Med Scund 205
12
S. Rusmus.sen et u l .
Table I . 1ncid~nc.c~ of C R and distribirtion by sex und cige in 2244 pcitients \tith AM1 ~
~~~
Age group
Male5
Females
Both \exes
All ca5es of AM1 CR in AM1
All cases ot AM1 CR in AM1
All c'ise5 of AM1 CR in AM1
n
all AM1
n
%
~
Cardiac Rupture in Acute Myocardial Infarction A Review of 72 Consecutive Cases Sten Rasmussen, Arne Leth, Erik Kjsller and Asger Pedersen From the Department of Cardiology, Copenhagen County Hospital, Glosrrup, Denmark
ABSTRACT. The occurrence of rupture of the external cardiac wall (CR) in a consecutive series of 2 244 admissions with confirmed acute myocardial infarction (AMI) has been analysed. The series comprises the unselected admissions to a single department, evaluated according to uniform criteria, with postmortem examination in 95 % of fatal cases. The incidence of CR was 3.2% af all cases of AMI, and 12.6% of all deaths. CR was significantly more frequent in women than in men, and in both sexes significantly more frequent after the age of 60, though the age distribution did not differ significantly from that of the patients dying from other causes. Moreover, CR was significantly more frequent in anterior wall infarctions, and in patients with no previous AMI. The majority of CR (84%) occurred within the first week, and a considerable part (32 %) within the first 24 hours after the onset of infarction. According to findings at autopsy, CR was accompanied particularly often (in 71 %) by complete occlusion of a major coronary artery. Autopsy findings gave no evidence that attempts at resuscitation, including external cardiac massage (65 patients), as well as intracardial injections (55 patients) and transthoracic introduction of a pace catheter (3 patients), could have any connection with the development of CR. The usual strict immobilization of the patients was applied during the first part of the series, but in the latter half (1 337 admissions) the patients were allowed to be out of bed from the first day with no imposed immobilization at all. The incidence of CR did not change significantly throughout the period, and the indication for maintaining the traditional immobilization of patients with AM1 is questioned. Key words: cardiac rupture, acute myocardial infarction, physical activity. Acta Med Scand 205: 1 I , 1979.
Myocardial rupture (CR) is a well known and almost invariably fatal complication to acute myocardial infarction (AMI) ( I ) . Physical activity in patients with fresh infarction has been suspected as
a precipitating factor, and this assumption has been
the major reason for the traditional prescription to these patients of a period of strict bed rest followed by gradual mobilization and gradual return to work. In this paper the incidence of rupture of the free wall and the hospital lethality have been followed in a large consecutive series of patients with AM1 treated with and without strict bed rest and immobilization during the acute phase. PATIENTS AND METHODS The report is based on a consecutive series of patients with AM1 admitted to a medical department during the years 1959-73, and from 1%6 to the Coronary Care Unit (CCU), of Copenhagen County Hospital, Glostrup. The hospital serves a well defined area from which all cases of suspected AM1 care are admitted without any preselection in relation to age or complicating diseases. This 14-year period can be divided into four stages, representing development from the non-monitored general medical ward with the traditional coronary regime to the full-time monitored CCU without immobilization of the patients. Period A . From 1959 to 1966 a general medical ward without ECG monitoring. All patients with AM1 were prescribed strict bed rest for up to eight days followed by gradual mobilization and discharge after four weeks. Period B . In the following two years patients with AM1 were monitored in a CCU for an initial period averaging three days, and were then transferred to a general medical ward. During their stay in the CCU they had some liberty to move around; but after transfer to the medical ward the traditional regime of immobilization was followed. Period C+D. During the subsequent four years the CCU was enlarged, so that patients with confirmed AM1 were now kept for the whole period of admission, i.e. for surviving patients at least 21 days after AMI. From 1968 to 1970 (period C) the patients were monitored for an average of five days. From 1971 to 1973 (period D) and later, the Reprint requests to: A. Pedersen, M.D., Cardiological Department, Copenhagen County Hospital, DK-2600 Glostrup, Denmark. Abbreviations: CR=myocardial rupture, AMI=acute myocardial infarction, CCU =coronary care unit. Acta Med Scund 205
12
S. Rusmus.sen et u l .
Table I . 1ncid~nc.c~ of C R and distribirtion by sex und cige in 2244 pcitients \tith AM1 ~
~~~
Age group
Male5
Females
Both \exes
All ca5es of AM1 CR in AM1
All cases ot AM1 CR in AM1
All c'ise5 of AM1 CR in AM1
n
all AM1
n
%
~
