about 60 y old patient without typical clinical afflictions of myocardial ischemia (Diabetes type 2 is known: silent ischemia? or only indolent aptient?). The patient was admitted to our ER with weakness and diarrhoea.
In ECG we found a sign of myocardial infarction stadium I-II in inferior leads, no signs of disturbance in V1-V6. Also we heard a new heard murmur (holosystolic murmur in Erb-point). Blood-sample showed us distinct elevated liver enzymes (GOT > 1000 U/l, GPT > 800 U/L) and severe disturbance of electrolytes (Na 115 mmol/l, K 5,8 mmol/l); lactate was elevated with 4,8 mmol/l with respiratory compensation.
In TTE I found a inferior (pseudo-)aneurysm with perforation (VSD) in right ventricle (inferior-septale) with acute leading pressure and secundary volume overload of right ventricle. Overall signs of acute RV-failure (maybe a myocardial infarction of right ventricle too).
Definitely NO clinical afflictions; NO haemodynamic instability.