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Elderly female with a history of hypertension, stroke, and, 1 month before, heart attack with cardiac arrest. The patient presented to the emergency department with 1 day of nausea, vomiting, cold sweats, and malaise. Troponins 1.54. ECG with inferior Q waves but no ST elevation/depression or T-wave inversion.

Chest radiograph shows an enlarged cardiac silhouette, for which a differential of cardiomegaly or pericardial effusion was suggested, as well as increased pulmonary vascular markings compatible with pulmonary congestion. Compared chest radiograph findings to the images from the methamphetamine-induced cardiomyopathy case.

CT angiography shows both cardiomegaly as well as an intermediate-density pericardial effusion (magenta arrows) concerning for hemopericardium. Most concerningly (holy-shit concerningly), there is a left ventricular aneurysm with rupture and blush of contrast (red arrow) into the hemopericardium, compatible with ongoing bleeding.

It is not surprising that a rupture of the heart carries high mortality risk. The patient passed away from PEA cardiac arrest shortly after admission, likely from cardiac tamponade by the enlarging hemopericardium.

60 year old male with a history of homelessness, latent tuberculosis, and methamphetamine abuse. The patient was admitted to the hospital for shortness of breath and leg edema. A urine drug test on admission was positive for methamphetamine.

Chest radiograph (right) shows an enlarged cardiac silhouette, for which a differential of cardiomegaly or pericardial effusion was provided. Subsequent echocardiogram confirmed this was cardiomegaly with a low ejection fraction. The pulmonary vascular markings on the chest x-ray are also prominent, compatible with congestion from heart failure. The patient has a normal past chest radiograph (left) that provides an easy comparison for these findings.