Myocardial infarction with non-obstructive disease and anomalous coronary origin: look for the common in the uncommon

Area of Science:

• Cardiology
• Cardiovascular Surgery
• Medical Imaging

Background:

• Management of congenital coronary artery anomalies (CAA) is challenging due to their rarity and diverse presentations.
• Coronary artery anomalies (CAA) are not integrated into current algorithms for myocardial infarction with non-obstructive coronary arteries (MINOCA).
• Surgical repair is suggested for symptomatic anomalous aortic origin of a coronary artery, complicating MINOCA management.

Observation:

• A 35-year-old male presented with suspected myocardial infarction.
• Coronary angiography revealed an anomalous origin of the left coronary artery from the right Valsalva sinus with a pre-pulmonic course.
• Stress cardiac magnetic resonance imaging showed recent myocarditis but no inducible ischaemia.

Findings:

• The case demonstrates a complex presentation of congenital coronary artery anomaly (CAA) in the context of myocardial infarction with non-obstructive coronary arteries (MINOCA).
• Accurate diagnosis and risk stratification are crucial, particularly when clinical scenarios are confounded by conditions like myocarditis.
• The interplay between CAA, MINOCA, and myocarditis necessitates careful evaluation beyond standard algorithms.

Implications:

• This case underscores the need for updated clinical guidelines to incorporate CAA management within MINOCA protocols.
• Accurate risk stratification is essential for determining appropriate treatment strategies in patients with complex CAA.
• Further research is required to standardize the approach to congenital coronary artery anomalies presenting with acute coronary syndromes.