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This editorial refers to ‘Effect of thrombolytic therapy on the risk of cardiac rupture and mortality in older patients with first acute myocardial infarction’† by H. Bueno et al ., on page 1705 Free wall rupture (FWR) is a catastrophic mechanical complication of ST segment elevation myocardial infarction (STEMI), which occurs in up to 8% of patients and is responsible for nearly 20% of all infarction-related deaths. In fact, next to cardiogenic shock due to pump failure, FWR is the most common mechanical cause of death in STEMI patients, occurring eight to 10 times more frequently than rupture of a papillary muscle or rupture of the interventricular septum. Although the vast majority of FWRs occur within the first week following symptom onset, up to half occur within the first 24 h. FWR primarily affects the left ventricle and complicates anterior and inferior infarctions similarly. When FWR occurs, the clinical presentation is dramatic, with the rapid development of hypotension, cardiac tamponade, pulseless electromechanical activity, and death. Unfortunately, the mortality rate is >90%, and few patients can be salvaged by anything other than heroic measures, including emergent pericardiocentesis and surgical repair.Both the choice and the timing of reperfusion therapy for STEMI have been implicated in the development of FWR. Early studies of STEMI patients randomized to fibrinolytic therapy (FT) or placebo showed a paradoxical increase in early mortality in those treated with FT, which could not be explained by an increase in stroke or major bleeding; this early mortality was attributed to the development of FWR.More recently, data from studies comparing primary percutaneous coronary angioplasty (PCI) with FT showed a significantly lower risk of FWR in patients treated with primary PCI.1 Several possible mechanisms have been proposed … *Corresponding author. Tel: +1 214 645 7528; fax: +1 214 645 7501. E-mail address : james.delemos{at}utsouthwestern.edu

european heart journal

Free wall rupture in the elderly: deleterious effect of fibrinolytic therapy on the ageing heartThe opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology.