Chest Discomfort: Could Coronary Pathology Extend Beyond Atherosclerosis?

Background/Objectives: Non-atherosclerotic pathological findings on coronary arteries involve various disorders that might lead to myocardial ischemia, independent of plaque complications and consequent lumen narrowing and obstruction. These patients often present with non-specific symptoms such as shortness of breath, rapid fatigue, and exertional chest tightness. When the underlying causes are non-atherosclerotic, these findings are frequently overlooked in radiology reports as a possible differential diagnosis. Therefore, the objective of this paper is to present the role of multidetector computed tomography (MD CT) coronary angiography in the diagnostic work-up of patients with rare but clinically valuable non-atherosclerotic pathological conditions of coronary arteries. Methods: We performed a literature search on Medline (via PubMed) for works presenting data on rare, non-occlusive, pathological findings on coronary arteries. Results: The review of the collected literature was performed in a narrative manner, intended to summarize mainly findings of imaging characteristics of non-occlusive pathologies: myocardial bridge, coronary aneurysm, ectasia, fistula, stenosis, and dissection. MD CT images of selected cases that were examined at our department, showing non-occlusive pathological changes in the coronary arteries, are displayed in planar and/or volume-rendered formats. Conclusions: Non-atherosclerotic abnormalities of the coronary vessel wall should be considered in the differential diagnosis of coronary causes of chest pain, dyspnea, and arrhythmias, as they may lead to both acute and chronic myocardial ischemia. Based on the presented literature and specific cases from our clinical practice, MD CT is shown to be an important tool for the rapid, non-invasive evaluation of non-atherosclerotic pathologies.