A rare coronary anomaly unmasked by ST abnormalities on 24-h Holter: a case report

Abstract

Coronary artery anomaly is an important cause of sudden death mainly in young adult athletes. Although rare, this clinical condition requires high clinical suspicion since its presentation is quite unspecific and variable. We described a case of a young female referred to the emergency department with significant dyspnea during physical exertion. Her clinical examination was unremarkable. Her rest electrocardiogram did not show specific ST segment or T wave abnormalities and the two-dimensional echocardiogram was normal. Because she reported palpitation a 24-h Holter was applied and it showed ST segment depression reaching up to 2.5 mm. Considering the symptoms of dyspnea in a young patient with not apparent anatomical cause by two-dimensional echocardiogram, a coronary computed tomography angiography was performed. It demonstrated anomalous origin of right coronary with trajectory between aorta and pulmonary artery and no coronary obstruction in coronary artery. After diagnosis, the patient was submitted to surgical reimplantation of the ostium of the right coronary. During the in-hospital post-operative stay, the patient had full recovery and no complications. She was discharged briefly and returned asymptomatic one month after the procedure. We describe a rare case of coronary anomaly that was unmasked after persistence of the dyspnea and lowered ST segment on 24-h Holter leading to the indication of coronary computed tomography angiography. Thus, this case highlights the importance of the clinical suspicion of coronary abnormality in young patients with pathological variation on ST segment and demonstrates the value of the coronary computed tomography angiography in this clinical scenario.