Risk factors, subtype profiles, and outcomes of cardiac rupture after acute myocardial infarction: a case-control study

Background Cardiac rupture (CR) is a fatal mechanical complication of acute myocardial infarction (AMI) with mortality rates exceeding 50%. Early identification of high-risk patients remains clinically important, especially in regions with delayed presentation and limited contemporary data. Methods This retrospective case-control study included 71 unique patients with CR [free wall rupture (FWR) 39, ventricular septal rupture (VSR) 28, papillary muscle rupture (PMR) 4] and 213 AMI controls without mechanical complications (1:3 ratio, stratified by AMI type) from a tertiary hospital in Wuhan, China (June 2020–December 2025). Factors independently associated with CR were identified using multivariable logistic regression with the events-per-variable principle (≥10). Model discrimination was assessed by the C-statistic and calibration by the Hosmer-Lemeshow test. Subtype comparisons (FWR vs. VSR), early (≤3 days) vs. late (>3 days) rupture analysis, and in-hospital mortality correlates were also evaluated. Results Patients with CR were older (69.6 ± 8.5 vs. 59.5 ± 11.7 years, P < 0.001), more frequently female (40.8% vs. 12.2%, P < 0.001), and had longer onset-to-door times (median 48 vs. 5 h, P < 0.001). In multivariable analysis, absence of emergency percutaneous coronary intervention (PCI) [odds ratio (OR) = 8.23, 95% confidence interval (CI) 3.45–19.66], Killip class III–IV (OR = 6.82, 95% CI 2.68–17.35), female sex (OR = 3.41, 95% CI 1.41–8.26), and lower serum albumin (OR = 0.84 per g/L, 95% CI 0.77–0.91) were independently associated with CR. FWR showed markedly higher mortality than VSR (97.4% vs. 57.1%, P < 0.001). Early rupture (≤3 days, 39.4%) was associated with more intense inflammatory activation and higher admission troponin, whereas late rupture (>3 days, 60.6%) was associated with lower albumin and markedly delayed presentation, appearing to correspond to different temporal clinical patterns. Surgical repair was the only factor associated with lower in-hospital mortality in the multivariable model (OR = 0.06, 95% CI 0.01–0.36, P = 0.002). Conclusions Absence of emergency PCI, Killip class III–IV, female sex, and hypoalbuminemia were independently associated with CR after AMI. FWR and VSR showed different clinical and hemodynamic patterns. Surgical repair was associated with lower in-hospital mortality among selected CR patients, supporting prompt multidisciplinary evaluation while recognizing the likelihood of survivor and indication bias.