**Introduction/Hypothesis**
Left ventricular free wall rupture (FWR) is a lethal mechanical complication of STEMI that has decreased due to advancements with revascularization.

**Methods (e.g. case series, trial or case report)**
Case Report

**Results**
A 66-year-old female with hyperlipidemia and tobacco use was admitted for a late presenting anterior STEMI. A week prior, the patient experienced anginal symptoms that self-resolved. However, she saw her primary care physician a week later during which an ECG revealed an old anterior infarct pattern with ST elevations in V3-V6. On arrival at the hospital, she was hemodynamically stable and asymptomatic. Labs were unremarkable except for mildly elevated troponin. Initial TTE revealed preserved LVEF with a left anterior descending (LAD) wall motion abnormality without pericardial effusion. Coronary angiography was not pursued given her late presentation and lack of symptoms. Twelve hours later, the patient suffered a PEA cardiac arrest. Repeat TTE showed newly reduced LVEF 30% and FWR of the mid to apical anterior wall with acutely expanding hemorrhagic pericardial effusion. Ultimately, the patient passed.

**Conclusion**
Revascularization in the setting of a late presenting MI with Q waves is of questionable benefit based on the Occluded Artery Trial (OAT) data. Management of FWR is challenging and highly dependent on an early diagnosis. FWR often presents as an out-of-hospital cardiac arrest. However, clinicians must maintain FWR on the differential even in late-presenting STEMI patients who are hemodynamically stable.



A TICKING TIME BOMB - A CASE OF LATE LEFT VENTRICULAR FREE WALL RUPTURE