Incidentally Diagnosed Anomalous Right Coronary Artery with an Interarterial Course Presenting as Chest Pain

Abstract

The frequency of advanced cardiopulmonary imaging has increased the incidence of diagnosis of coronary artery anomalies, but this poses an interesting management dilemma of what to do with them once these anomalies are found. We present the case of a 57-year-old female with a past medical history of postpartum cardiomyopathy, recovered heart failure with reduced ejection fraction (EF), and alcohol use disorder who presented with chest pain, shortness of breath, nausea, vomiting, and palpitations. A CT angiogram was performed to rule out pulmonary embolism. No pulmonary embolism was found; however, the CT scan revealed an anomalous right coronary artery originating from the left coronary cusp, which had a malignant interarterial course (ARCA-LCC-IA) with a right dominant pattern of myocardial circulation. Subsequent nuclear stress testing did not show evidence of ischemia. Echocardiogram revealed a recurrently reduced EF of 40%. Our patient poses a management dilemma since she presented with possible angina and was found to have an anomalous right coronary artery (ARCA) with a malignant course, but subsequently she had a negative exercise stress test with nuclear perfusion imaging. We will review the literature on ARCA-LCC-IA and its clinical manifestations both generally and with its connection to this case as well as its management. We discuss the incidence, diagnosis, and management of ARCA-LCC-IA, with a focus on incidentally found lesions.

Malignant right coronary artery in an athlete: Evidence-less based medicine?

“…Malignant RCAs are rare, with an incidence of 0.17 to 1.2%. 1 Although the majority of patients remain asymptomatic during their lifetime, with most cases being incidentally discovered, malignant RCAs have been associated with both myocardial infarctions and sudden cardiac deaths, especially in young patients. Various contributing factors have been postulated, including mechanical compression between the aorta and pulmonary artery, the presence of valve like ridges, angulation of the artery as it courses and presence of a slit-like orifice.…”