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Post-MI VSR — RACP Adult Medicine MCQ

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HardCardiologyPost-MI VSRRACP Adult Medicine

A 60-year-old man with a history of anterior STEMI 4 weeks ago presents with progressive dyspnoea and a new pansystolic murmur loudest at the left sternal edge. Echocardiography shows a ventricular septal defect. What mechanical complication has occurred?

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Correct answer: E — Post-MI ventricular septal rupture

Post-MI ventricular septal rupture (VSR) typically occurs 3–5 days after MI (earlier with fibrinolysis, later without reperfusion). It presents with a new harsh pansystolic murmur at the left sternal edge, acute haemodynamic deterioration, and step-up in oxygen saturation from RA to RV on catheterisation. Differentiation from papillary muscle rupture (pansystolic murmur at apex, acute MR) is critical. VSR requires urgent surgical repair or percutaneous closure. Medical stabilisation with vasodilators and IABP/Impella is a bridge to surgery. Mortality without surgery exceeds 90%.

Reference: NHF/CSANZ – 2025 – ACS Guideline; ESC – 2023 – STEMI Guidelines