A rare cause of angina

Abstract

Anomalous coronary arteries are rare entities with very few symptomatic cases successfully managed non-invasively. We report a case of a 43-year-old female who presented subacutely with intermittent cardiac-sounding chest pain and an unremarkable past medical history. Serial Troponin I were negative and her ECG showed no dynamic ischaemic changes. An exercise stress test was electrically and symptomatically negative for ischaemia. A myocardial perfusion scan with persantin stress test provoked chest pain but was a negative perfusion scan. A diagnostic coronary angiography demonstrated the left main stem (LMS) originating from the proximal right coronary artery and a single coronary opening in the aorta with unobstructed coronary arteries (Figure 1 A). A further CT coronary angiogram (CTCA) demonstrated that the left main stem had the inter-arterial course running between the right ventricular outflow tract (RVOT) and aorta (Figure 1 B). Cardiac surgery with re-implantation of the LMS to the left coronary cuspid was explored, however this was declined after further negative exercise stress echo and dynamic CTCA demonstrated no evidence of compression of the LMS. High dose Metoprolol and nitrates only provided minimal chest pain relief. Therefore coronary artery spasm was considered and Diltiazem 360 mg once daily was trialled with optimal relief fromangina.Onfollow-up over three years, the patient is currently symptom free and enjoying her regular activities. In our experience, we found that the high dose Diltiazem was pivotal in managing this patient's anginal symptoms.<br />