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A case of recent myocardial infarction with cardiac failure
  1. Anishkumar Nair,
  2. Chakanalil Govindan Sajeev,
  3. Kader Muneer
  1. Department of Cardiology, Government Medical College, Kozhikode, Kerala, India
  1. Correspondence to Dr Anishkumar Nair, Department of Cardiology, Government Medical College, Medical College Road, Kozhikode, Kerala 673008, India; dr.anish84{at}


Clinical introduction A 50-year-old hypertensive smoker presented with a typical angina of 2 days duration. An urgent ECG revealed extensive anterior wall myocardial infarction. In view of the delayed presentation, the patient was conservatively managed with heparin. In-hospital echocardiogram showed akinesia of entire left anterior descending artery (LAD) territory with severe left ventricular (LV) dysfunction. He was discharged with a plan for early coronary intervention. However, he presented a fortnight later with acute pulmonary oedema. General appraisal revealed a restless individual who was dyspnoeic and diaphoretic at rest. On clinical examination, the patient was in hypotension with features of biventricular failure. A 12-lead ECG showed QS pattern with persistent ST segment elevation in precordial leads. The chest radiograph demonstrated features of pulmonary oedema, cardiomegaly and bilateral pleural effusion. Creatine Phosphokinase-MB (CPK-MB) was negative. A preliminary transthoracic echocardiography was done (figure 1 and see online supplementary video 1).

Figure 1

(A) Trans thoracic echocardiogram-apical 4 chamber view; (B) zoomed view of apex; (C) colour Doppler at left ventricular (LV) apex and (D) bulls-eye plot of strain imaging.

Question What is the most likely diagnosis based on the echocardiogram?

  1. LV pseudo-aneurysm with contained rupture

  2. Dissecting intramural haematoma of LV apex

  3. Ventricular apical aneurysm with thrombus

  4. LV non-compaction with prominent ventricular trabaculations

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