Figure 6: A 60-year-old male presented with severe acute chest pain and elevated troponins. 2D echocardiography revealed regional wall motion abnormality in the inferolateral wall and a thin rim of pericardial effusion. There was a suspicious free wall rupture on echocardiography, and hence, CMR was performed, after the patient was stabilized. Catheter angiography revealed 100% occlusion of the left circumflex artery and significant triple vessel disease. (a) Short-axis cine images at midcavity show thinning of the inferolateral segment with subtle signal abnormality (dashed red ellipse). Cine images revealed subtle tear with adjoining pericardial collection. (b) Routine short-axis LGE images (TI ~225 ms) show nonenhancing areas (MVO) within the myocardium with surrounding LGE. Pericardial effusion with a dark signal is also noted. (c) Long TI (~562 ms) LGE images show near-transmural LGE with low-signal intensity within it. Note increased contrast with the nonenhancing area (clot and MVO) and enhancing myocardium. (d) Precontrast T1 mapping shows near-isointense signal with increased signal intensity in adjoining pericardial sac (clot). (e) Postcontrast T1 mapping values show no significant drop in low-signal intensity area (MVO) along with the pericardial sac (clot). However, adjoining myocardium shows a reduced signal. (f) T2 mapping shows increased T2 values in the area of infarction. Final diagnosis: Acute inferolateral MI with free wall rupture and pericardial effusion with clot. These patients should not be given anticoagulants as this will aggravate rupture. Follow-up echocardiography in this patient showed the formation of pseudoaneurysm. 2D: Two-dimensional, CMR: Cardiac magnetic resonance imaging, LGE: Late gadolinium enhancement, MI: Myocardial infarction, ms: Milliseconds, MVO: Microvascular obstruction TI: Time to inversion