Complications after acute myocardial infarction — structured written assessment

SAQ 1 (10 marks)

Practice scenario. A 70-year-old woman presented 14 hours after symptom onset with an anterior STEMI and had primary PCI. On day 4 she becomes hypotensive and cool peripherally, with oliguria and a new pansystolic murmur at the lower left sternal edge. Her systolic blood pressure is 80 mmHg despite initial treatment.^[7]

1. Which mechanical complication is most likely, and which features and risk factors point to it? (2)^[7]
2. Which imaging is recommended now, with its ESC 2023 class and level, and what would right heart catheterisation show? (2)^[1][7]
3. Give the ESC 2023 rows on repair and on an intra-aortic balloon pump for her, with class and level. (2)^[1]
4. What does the ESC 2026 heart failure guideline say about temporary mechanical circulatory support here, including its footnote on a large ventricular septal defect? (2)^[3]
5. What does ACC/AHA 2025 say about where she should be managed and about the timing of surgery? (2)^[2]

Model answers — SAQ 1

1. A post-infarction ventricular septal defect: the AHA 2021 statement says clinical examination often reveals hypotension, cool peripheries and oliguria from low cardiac output, and a new pansystolic murmur, commonly at the lower left sternal edge, with signs of pulmonary venous congestion, typically 3 to 5 days after infarction (1 mark).^[7] Risk factors include older age, female sex and delayed reperfusion (1 mark).^[7]
2. ESC 2023: emergency transthoracic echocardiography is recommended in suspected ACS with cardiogenic shock or suspected mechanical complications (Class I, Level C); echo is diagnostic for the size and location of the left-to-right shunt (1 mark).^[1][7] Right heart catheterisation shows a diagnostic step-up in oxygenation between the right atrium and pulmonary artery, with an elevated pulmonary-to-systemic flow ratio (1 mark).^[7]
3. In cases of haemodynamic instability, emergency surgical or catheter-based repair of mechanical complications of ACS is recommended, based on Heart Team discussion (Class I, Level C) (1 mark).^[1] An IABP should be considered in patients with haemodynamic instability or cardiogenic shock due to ACS-related mechanical complications (Class IIa, Level C) (1 mark).^[1]
4. In the ESC 2026 table on temporary MCS in cardiogenic shock, temporary MCS should be considered in patients with mechanical complications related to MI as a bridge to definitive treatment (Class IIa, Level C), with passive IABP or active percutaneous MCS chosen by the Shock Team on the severity of shock (1 mark).^[3] In a large ventricular septal defect, temporary MCS should be used with caution, because VA-ECLS may increase the left-to-right shunt and a microaxial flow pump may cause shunt inversion (1 mark).^[3]
5. ACC/AHA 2025: patients with a mechanical complication of ACS should be managed in a facility with cardiac surgical expertise (COR 1, LOE C-EO) (1 mark).^[2] Early corrective surgery is the treatment of choice although exact timing is uncertain; mortality after delayed surgery (more than 7 days) is lower, but selection and survivor bias contribute, and surgical risk is highest in cardiogenic shock (1 mark).^[2]

SAQ 2 (10 marks)

Practice scenario. A 61-year-old man had primary PCI for an anterior STEMI involving the left anterior descending artery and is on dual antiplatelet therapy. His LVEF is 27%. On day 3 he develops pleuritic chest pain and a pericardial friction rub.^[2]

1. How does ACC/AHA 2025 diagnose post-MI pericarditis, and how do ESC 2023 and ACC/AHA 2025 time early and late forms? (2)^[2][1]
2. What does ESC 2025 say about aspirin in early post-AMI pericarditis and in its post-cardiac injury syndrome recommendations, and which drugs does ACC/AHA 2025 call potentially harmful? (2)^[4][2]
3. His echo shows a 13 mm pericardial effusion at end-diastole. What does ESC 2025 say? (1)^[4]
4. Why is he at high risk of LV thrombus, and how often is it found after anterior STEMI? (2)^[2][1]
5. His echo images of the apex are equivocal. Give the ESC 2023 imaging rows for LV thrombus, with class and level. (2)^[1]
6. If thrombus is confirmed, give the ESC 2023 anticoagulation row. (1)^[1]

Model answers — SAQ 2

1. ACC/AHA 2025 Table 18: pleuritic chest pain and at least 1 of a friction rub; ECG evidence such as classic PR depression or diffuse concave ST elevation or, in the setting of MI, persistent ST elevation or dynamic T-wave changes; or a new or growing effusion on echo (1 mark).^[2] ESC 2023: early infarct-associated pericarditis occurs from a few hours to 4 days after acute MI, and late pericarditis or post-cardiac injury (Dressler) syndrome typically 1–2 weeks after; ACC/AHA 2025 says early pericarditis typically arises 1 to 3 days after a transmural event, and a second form may occur weeks after MI (Dressler syndrome) (1 mark).^[1][2]
2. ESC 2025: in early post-AMI pericarditis a 5–7-day course of aspirin, with colchicine, seems the most reasonable option; its post-cardiac injury syndrome recommendations give high-dose aspirin as the first-choice anti-inflammatory therapy for post-MI pericarditis and in patients already on antiplatelet therapy (Class I, Level C) (1 mark).^[4] ACC/AHA 2025: glucocorticoids and NSAIDs other than aspirin are potentially harmful, because of a possible increase in the risk of recurrent MI or impaired myocardial healing and risk of rupture (1 mark).^[2]
3. A post-AMI pericardial effusion of more than 10 mm at end-diastole should be investigated for a possible subacute heart rupture (1 mark).^[4]
4. ACC/AHA 2025 lists anterior STEMI involving the left anterior descending artery, LVEF under 30% (especially with an LV aneurysm) and longer times to reperfusion as the highest-risk features (1 mark).^[2] ESC 2023: LV thrombus can be present in more than 9% after anterior STEMI by a large meta-analysis, and contemporary CMR data report it in 12.2% of those with anterior STEMI (1 mark).^[1]
5. CMR imaging should be considered with equivocal echocardiographic images or high clinical suspicion of LV thrombus (Class IIa, Level C) (1 mark).^[1] After an acute anterior MI, a contrast echocardiogram may be considered for detecting LV thrombus if the apex is not well visualised (Class IIb, Level C) (1 mark).^[1]
6. Oral anticoagulant therapy (VKA or NOAC) should be considered for 3–6 months in confirmed LV thrombus (Class IIa, Level C), weighing bleeding risk and the need for concomitant antiplatelet therapy (1 mark).^[1]