Medical Mystery of the Week

      You are on your emergency room elective and asked to examine a 62-year-old man who was just admitted with severe (grade 8) precordial chest pain of three hours duration. He has a history of hypertension, hypercholesterolemia, and type II diabetes melitus.
      Your cardiac exam is normal except for a barely preceptable double impulse felt medial to the left cardiac border. The patient's admitting EKG is shown below.
     While you are dictating the results of your history and physical examination, the patient's condition suddenly worsens. You rush to the bedside and find that his systolic blood pressure is 100 mm Hg during inspiration and 120 mm Hg during expration.
      DIAGNOSIS: Pulsus paradoxus in a patient with an acute anterior myocardial infarction complicated by right ventricular rupture and tamponade.
      Pulsus paradoxus is defined as a greater than 10mm Hg fall in systolic blood pressure during inspiration.
      Pulsus paradoxus is a misnormer in that it is not paradoxical but rather an accentuation of the normal fall in systolic blood pressure that occurs during inspiration. Normally, inspiratory expansion of the thorax decreases intrathoracic pressure, increases right ventricular return, and delays/diminishes left ventricular return causing a reflex increase in the pulse rate and a drop of ≤ 10 mm Hg in the systolic blood pressure.
      In addition to cardiac tamponade, pulsus paradoxus may occur in conditions where intrathoracic pressure swings are exaggerated or the right ventricle is distended such as occurs in severe acute asthma or exaccerbations of chronic obstructive pulmonary disease. Note that patients with cardiac tamponade may display Beck's triad (hypotension, increased jugular venous pressure, and quiet heart sounds). 
      Echocardiographically guided pericardiocentesis followed by surgical repair of the ruptured ventricle are the treatments of choice in patients with ventricular free wall rupture and tamponade.

Note the Q waves in leads II, III, AVR, AVF, and V1-V4. ST segments are elevated in V2-V5. These findings are characteristic of an acute anterior lateral myocardial infarction. Weakening (ischemia) of the right ventricular wall prior to rupture accounted for the double impulse noted on admission of the presented case.  

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