Article Text
Statistics from Altmetric.com
Description
A 61-year-old man with hypertension and dyslipidemia presented with exertional chest pain that improved after the administration of nitric oxide. A treadmill exercise ECG demonstrated down-sloping ST-segment depression in leads V4–V6 without chest pain (figure 1A, B). Stress myocardial perfusion scintigraphy revealed a lateral ischaemia (figure 1C). Coronary angiography revealed no significant stenosis in the left anterior descending artery (figure 2A, B), and a deficit of the left circumflex coronary artery (LCX) apparently. A careful re-examination of the angiography images revealed coronary flow of the LCX at the time of administration of contrast to the right coronary artery (RCA; figure 2C, D). The patient underwent cardiac CT scan for further evaluation of LCX. The CT scan identified an anomalous origin of the LCX arising from the right sinus of Valsalva near the RCA origin, with an extramural course between the aorta and the left atrium (figure 3A–C). It passed along the left atrioventricular groove and perfused the lateral wall. The proximal portion of the anomalous LCX was 75% occluded (figure 3D–E). We inferred that the anomalous LCX was the culprit artery. The patient was treated with 5 mg of carvedilol daily, and the symptom improved. The prevalence of anomalous origin of the LCX was reported to be 0.17%1 and the slit-like orifice and a narrow intramural distal artery might be an important cause of ischaemia.2 ,3 In our case, cardiac CT and exercise-stress testing identified the anomalous LCX and its atherosclerotic lesion in the long mid-portion as a cause of the patient's angina.
Learning points
-
A vascular area of one branch of coronary artery requires a high level of suspicion of an anomalous origin of a coronary artery.
-
Cardiac CT scan is a useful non-invasive modality that can be employed for the morphological assessment of and devising treatment for coronary artery diseases, particularly in cases with anomalous coronary arteries.
-
The slit-like orifice and a narrow intramural distal artery, which is longer than normal morphology and, possibly, more susceptible for atherosclerosis burden, might be an important cause of ischaemia in cases with anomalous coronary arteries.
Footnotes
-
Contributors MO and TK wrote the manuscript and MI supervised it.
-
Competing interests None.
-
Patient consent Obtained.
-
Provenance and peer review Not commissioned; externally peer reviewed.