131: ANOMALOUS RIGHT CORONARY ARTERY WITH AN INTERARTERIAL COURSE ORIGINATING FROM THE LEFT CORONARY CUSP

Abstract

Introduction: Anomalies of coronary arteries arising from the opposite sinus are extremely rare, with an estimated prevalence of anomalous right coronary arteries arising from the left coronary cusp varying between 0.026 and 0.25%. While largely incidental, symptomatic patients vary in presentation. This case describes a young patient with no cardiac history who presented with acute coronary syndrome and was found to have an anomalous origin of the right coronary artery (RCA). Methods: Data was collected during the admission and follow-up a year later. Results: A 27-year-old male with a history of recent cocaine use presented to the hospital with several hours of chest pain described as constant, substernal, pressure-like, exertional, and with radiation to both arms. Laboratory analysis on admission showed normal cardiac biomarkers but the ECG showed ST-elevations in multiple inferior leads. Emergent cardiac catheterization with coronary angiography showed no epicardial or occlusive coronary artery disease; however, it did show an abnormal origin of the RCA. Subsequent CT angiogram of the coronary arteries confirmed an anomalous origin of the RCA from the left coronary cusp with an interarterial course between the aorta and the pulmonary artery, with concerns for impingement. Troponin level trended up to 21 ng/mL; however, we were unsure whether this was secondary to cocaine-induced vasospasms, RCA impingement, or a combination of both. Echocardiogram (ECHO) showed a normal ejection fraction with no valvular or wall motion abnormalities. Patient tolerated the stress test well, tolerating 11+ METS, which revealed no significant ECG changes and minimal areas of ischemia. Following discussion with all the cardiac specialties involved, the patient decided to hold off surgery at this time and continue with conservative medical management. Cocaine abstinence was advised. The patient has had no recurrent episodes in over a year. Conclusions: Coronary anomalies should be suspected in symptomatic young patients with acute coronary syndrome. Given the rarity of this condition, many physicians may be unaware of this disease and should consider this as a differential diagnosis. While surgical intervention is considered first line treatment in many cases, medical management remains a suitable option in select patients.