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Aortic stenosis
6%
15/236
Ventricular wall aneurysm
10%
23/236
Restrictive pericarditis
13%
31/236
Papillary muscle rupture
65%
153/236
Arrhythmia
2%
5/236
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The most likely diagnosis is new onset mitral regurgitation in the setting of a ruptured papillary muscle which presents as sudden left sided heart failure and pulmonary vasculature congestion 3-7 days after myocardial infarction. Papillary muscle rupture occurs approximately 3-7 days after a MI. The posteromedial papillary muscle is the most commonly injured due to its single blood supply from the posterior descending coronary artery, which is involved in posterior wall MI. During this time period, the recovering myocardium is at its weakest integrity leading to septal, ventricular wall, or papillary muscle ruptures. Since papillary muscles hold the leaflets of the mitral and tricuspid valves to prevent backflow during systole, rupture of a papillary muscle in the left ventricle would lead to acute mitral valve regurgitation which is heard as a holosystolic murmur at the apex or left sternal border of the heart. Mitral regurgitation would present with signs of pulmonary volume overload such as the bibasilar crackles and dyspnea as seen in this patient. Incorrect Answers: Answer 1: Aortic stenosis presents with a holosystolic murmur; however, it does not acutely occur after MI. Causes of aortic stenosis would include age-related calcification, congenital bicuspid aortic valves, and rheumatic heart disease. Answer 2: Ventricular wall aneurysms occur about >2 week after MI and can progress to left-sided congestive heart failure. In certain cases, ventricular wall aneurysms may result in inability of the mitral valve leaflets to close properly, and could present with mitral regurgitation. Answer 3: Fibrinous pericarditis can occur 1-3 days post-MI and would present with a friction rub instead of a holosystolic murmur. Additionally, Dressler syndrome is a late onset pericarditis that can occur 2-3 weeks or more after MI which would also present with a pericardial friction rub instead of a new murmur. Answer 5: Arrhythmias occur most often within the first 24 hours post-MI due to hypoxia, electrolyte release from necrotic tissue, or reperfusion injury. Bullet Summary: Papillary muscle rupture, ventricular wall rupture, and ventricular wall aneurysm are complications that occur 3-7 days post-MI.
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