Fatal Cardiac Rupture During Stress Exercise Testing: Case Series and Review of the Literature

Laurence Weinberg, BSC, MBBCH, MRCP; Karikalan Kandasamy, MBBS, MD, MRCP; Stephen J. Evans, MRCP, PhD; Joseph Mathew, FMCPATH, FRCPATH, CERT THLE, PGCE, MBBS

Disclosures

South Med J. 2003;96(11) 

In This Article

Abstract and Introduction

Mortality rates of exercise testing are low and cardiac rupture and sudden death are rare. Three cases of fatal cardiac rupture that occurred during exercise stress testing are reported. Once thought to be a fatal complication, there are increasing reports of ante-mortem diagnosis and survival. Cardiac rupture is a stuttering process with recognizable clinical symptoms that allow early recognition and treatment. Certain clinical, biochemical, ECG and hemodynamic markers may allow identification of patients likely to sustain rupture. Strategies for diagnosis, resuscitation, and definitive intervention are reviewed.

Exercise stress testing is a common procedure used in the evaluation of chest pain. It is increasingly being deployed as a risk-stratifying tool for patients presenting to hospital with acute coronary syndromes. The current guidelines for the management of unstable angina and non-ST segment elevation myocardial infarction (MI) propose initial medical therapy and then either an early invasive approach with angiography or alternatively, a conservative approach.[1,2] The latter is for patients who are not in a high-risk category or who do not develop recurrent chest pain. Here, simple exercise treadmill testing in patients with normal electrocardiograms (ECGs) may be done or increasingly, exercise or pharmacological stress testing in conjunction with an imaging modality such as nuclear or echocardiography is used. Stress testing is also advocated in stable patients post-MI who have received thrombolytics several days before, to assess the extent of residual ischemia. A submaximal stress test is usually administered on or approximately on Days 3 to 5 while a symptom-limited stress test may be safely performed approximately 4 to 6 weeks after MI.[3] Three cases of fatal cardiac rupture during exercise testing that occurred in an exercise laboratory during an 18-month period are reported. We discuss whether certain clinical events may precede free wall myocardial rupture and allow its prediction, and review strategies for diagnosis, resuscitation, and definitive intervention.

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