When ventricular free wall rupture after acute myocardial infarction is not followed by sudden death, it is referred to as subacute ventricular rupture. The sensitivity and specificity of clinical, hemodynamic and echocardiographic diagnostic variables obtained at bedside are unknown and were therefore prospectively studied in 1,247 consecutive patients with acute myocardial infarction including 33 patients with subacute ventricular rupture diagnosed at operation (group A) and 1,214 patients without ventricular rupture (at operation, postmortem study or at discharge) (group B). The incidence of syncope, recurrent chest pain, hypotension, electromechanical dissociation, cardiac tamponade, pericardial effusion, high acoustic intrapericardial echoes, right atrial and right ventricular wall compression identified in two-dimensional echocardiograms and hemopericardium demonstrated during pericardiocentesis was higher in group A than in group B (p less than 0.00001). The presence of cardiac tamponade, pericardial effusion greater than 5 mm, high density intrapericardial echoes or right atrial or right ventricular wall compression had a high diagnostic sensitivity (greater than or equal to 70%) and specificity (greater than 90%). The number of false positive diagnoses was always high for each diagnostic variable alone (greater than 20%), but the combination of clinical (hypotension), hemodynamic (cardiac tamponade) and echocardiographic variables allowed a sensitivity of greater than or equal to 65% with a small number of false positive diagnoses (less than 10%) and provided useful information for therapeutic decisions. The diagnosis of subacute ventricular rupture requires a surgical decision. Twenty-five (76%) of the 33 patients with subacute ventricular rupture survived the surgical procedure and 16 (48.5%) are long-term survivors. Thus, subacute ventricular wall rupture is a relatively frequent complication after acute myocardial infarction that can be accurately diagnosed and successfully treated.

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RESUMENLos enfermos psiquiátricos, y concretamente los esquizofrénicos, manifiestan en ocasiones síntomas somáticos cuya interpretación es difícil lo que puede dar lugar a errores de diagnóstico diferencial con una patología orgánica. En el caso del infarto agudo de miocardio el error diagnóstico puede llegar a ser fatal con las lógicas repercusiones médico-forenses que se derivan de esta situación. En este artículo presentamos el caso de un paciente con un trastorno psiquiátrico perfectamente diagnosticado y tratado (esquizofrenia paranoide) asociado a una cardiopatía isquémica que debuta clínicamente con un infarto agudo de miocardio. No obstante, la sintomatología somática manifestada por el paciente fue atribuida a su proceso psicopatológico de base por lo que no se le prestó atención médica y se produjo el fallecimiento de forma súbita. En la autopsia médico-forense se encontró un taponamiento cardiaco secundario a la ruptura de la pared libre del ventrículo izquierdo por infarto agudo de miocardio. Se revisa la literatura sobre la ruptura de la pared libre del ventrí-culo izquierdo como complicación de un infarto agudo de miocardio atendiendo a sus características clínicas, frecuencia, factores de riesgo y anatomía patológica. Los estudios médico-forenses ponen de manifiesto que la frecuencia de esta complicación es muy superior cuando la muerte se produce en el medio extrahospitalario que cuando ocurre en el medio hospitalario. Palabras clave: Infarto agudo de miocardio, ruptura miocárdica, autopsia médico-forense, enfermedad psiquiátrica, comorbilidad. ABSTRACTPsychiatric patients, mainly schizophrenics, have occasionally somatic symptoms that are difficult to interpret leading to errors in the differential diagnosis with an organic illness. In the case of the acute myocardial infarction, the diagnostic's mistake may be fatal with the logical medico-legal repercussions derived from this situation. In this paper we present the case of a patient with a mental disorder perfectly diagnosed and treated, (Paranoid Schizophrenia), associated with an ischemic cardiopathy which starts clinically with an acute myocardial infarction. However, the somatic symptoms where attributed to his mental disorder and no medical attention was demanded, leading to his sudden death. In the forensic autopsy a cardiac tamponade was found secondary to a left ventricular free wall rupture due to myocardial infarction. Medical literature about this complication of acute myocardial infarction is reviewed considering clinical aspects, frequency, risk factors and pathology. Medico-legal studies have shown that this complication is more frequent when the death occurs out-of-hospital as opposed of death occurring in-hospital.