Coronary Artery Disease with Anomalous Origin of Left Coronary Artery from the Proximal Right Coronary Artery REPLACE THIS BOX WITH YOUR ORGANIZATION’S HIGH RESOLUTION LOGO REPLACE THIS BOX WITH YOUR ORGANIZATION’S HIGH RESOLUTION LOGO Dean Strinić, MD; Dario Gulin, MD; Jozica Šikić, MD, PhD University Hospital „Sveti Duh” Zagreb, University of Zagreb School of Medicine Introduction Anomalous origin of coronary arteries can sometimes be associated with acquired heart disease including coronary artery disease or heart valve disorders. Acute myocardi­al infarction has been reported in patient with anomalous origin of coronary arteries. In this case report we present a patient with anomalous origin of left coronary artery from the proximal right coronary artery, which by itself can be a cause of myocardial ischaemia, and significant coronary artery disease. Figure 2. Incidence and Causes of Sudden Death in U.S. College Athletes, JACC, 2014. Discussion and conclusion Anomalous origin of left coronary artery is an incidental finding during coronary angiography in our patient with symptomatic ischaemic heart disease. There is no typical clinical presentation of a patient with anomalous origin of coronary arteries. Most patients are asymptomatic for a large portion of their lives, and an atypical chest-pain syndrome is the most common reason they are referred for coronary angiography. Other possible manifestations are dyspnea, dizziness, palpitations and syncope. Unfortunately, the first clinical symptom may be sudden death, particularly in young athletes and military recruits (Fugure 2). Whereas sudden death is usually associated with extreme exercise in young adults, the other manifestations are more frequently seen in older adults and are related to the onset of hypertension. Overall, the incidence of sudden death in patients with anomalous origin of coronary arteries is low, though higher for patients with anomalous origin of the LCA than with ACAOS of the right coronary artery, especially in the absence of symptoms. Not only origin of coronary artery makes symptoms related to ischemia but also the course of the anomalous vessel. As coronary angiography gives two-dimensional view, other imaging as echocardiography, MSCT coronary angiography or MR could be used to define the course and impact of other structures on vascular lumen. Figure 1. Different aomalous origins of LCA from RC sinus (Kim S Y at al. Radiographics 2006;26:317-333.) Case report 73-year-old male patient with coronary artery disease, previously treated with coronary stenting in right coronary artery in 2005, presented to the emergency unit due to chest pain and sudden onset of palpitations from that morning. Electrocardiogram showed atrial fibrillation with ventricular rate of 160 beats per minute and deep ST depression for up to 0.4 mV in anterolateral leads from V4-V6. Repeated troponin levels confirmed the diagnosis of non-ST elevation myocardial infarction. Urgent coronary angiography was performed which showed anomalous origin of left coronary artery from the proximal right coronary artery, diffuse atherosclerotic changes, non-significant changes in left anterior descending and circumflex artery, without changes in previously implanted stent in right coronary artery and 50% stenosis in distal part. Figure 3. Figure 4. Figure 5. Contact References Dario Gulin, MD University Hospital „Sveti Duh” Zagreb Svwti Duh 64, 10000 Zagreb Email: dariogulin@gmail.com Website: www.kbsd.hr Phone: +385 91 3713 398 Tuo G, Marasini M, Brunelli C et al. Incidence and clinical relevance of primary congenital anomalies of the coronary arteries in children and adults. Cardiology in the Young 2013;23,381-386. Krupinski M, Urbanczyk-Zawadzka M, Laskowicz B et al. Anomalous origin of the coronary artery from the wrong coronary sinus evaluated with computed tomography: „High risk“ anatomy and its clinical relevance. Eur radiol 2014;24(10):2353-9. Angelini P, Velasco JA, Flamm S. Coronary anomalies: Incidence, pathophysiology and clinical relevance. Circulation 2002;105:2449-2454.