Of 2608 consecutive patients with acute myocardial infarction, 24 developed subacute free wall rupture (= 0.92%; 95% C.I. = 0.6-1.4). Clinical manifestations varied widely (shock on admission; 25% of cases; severe arrhythmias followed by shock: 17%; shock during hospital stay: 42%; symptoms suggestive of infarct extension without shock: 17%). The electrocardiograms were confusing rather than revealing: 56% of patients showed new ST segment elevations of 0.2 to 1 mV in the infarct-related leads, while autopsy or creatinine phosphokinase evidence of infarct extension was missing. In the first 21 cases, therefore, no definitive diagnosis was made before autopsy. Using 197 infarct patients in cardiogenic shock or with infarct extension during the acute stage, i.e. a patient group with comparable clinical manifestations, as control group, a logistic regression model was generated in which the variables age, lateral wall involvement and history of hypertension were used for estimating the probability of subacute rupture. In fact, probability may rise to more than 40% in major subgroups. As death occurred after a median interval of 8 h (45 min-6.5 weeks) following the onset of rupture symptoms, echocardiography must be performed urgently in all cases presenting symptoms of shock or infarct extension. Pretest probability which can be roughly estimated from our model as well as sensitivity and specificity of individual echocardiographic or clinical parameters are indispensable for correct therapeutic decisions. The routine application of this algorithm in our department contributed to a timely diagnosis in the last three consecutive cases of whom one patient survived.

581 consecutive patients admitted to hospital for acute myocardial infarction between January 1983 and June 1985 were divided into two groups. Group A (286) patients were aged 70 years or over (76 +/- 4 years); those in group B (246) were 65 or younger (56 +/- 8 years). Group A patients had a significantly higher incidence of anterior-wall infarction (30% vs. 18% in group B); heart failure (55% vs. 32%); pulmonary oedema (18% vs. 6%); cardiogenic shock (17% vs. 6.5%); or rupture (6% vs. 2%). Patients of the older age group also significantly less often underwent systemic fibrinolysis (0.3% vs. 21%); coronary angiography (2% vs. 61%); percutaneous transluminal coronary angioplasty (PTCA) or aorto-coronary bypass operation (0% vs. 22%) (P = 0.00001). Among the older patient group the cumulative mortality rate during hospitalization was 26.9% vs. 11.8% in group B, after six months it was 39% vs. 15%, after 12 months 46% vs. 17%, and after 24 months 61% vs. 21% (P = 0.00001). Causes of death were comparable in the two age groups, cardiac ones predominating. Angina in NYHA classes III-IV after discharge was present in 10% of the younger but 38% among the older patients (P = 0.00001). The death rate in patients of group A was very high under conservative treatment and surviving patients had a poor quality of life. Yet both coronary artery surgery and PTCA gave demonstrably better long-term results, both as to function and survival. Therefore, patients of even this higher age should more than is the case at present be more aggressively treated with invasive diagnostic and therapeutic procedures.