Challenges of Managing Acute Coronary Syndromes in Patients With Congenital Single Coronary Artery

Single coronary artery (SCA) is a rare congenital disorder representing 0.024%-0.066% of the population. Patients with SCA presenting with acute coronary syndromes (ACS) pose diagnostic and treatment challenges. This case series demonstrates the clinical diversity and management challenges of three patients with SCA. The first patient is a 58-year-old gentleman who presented with non-ST-elevation myocardial infarction (NSTEMI) and was found to have an anomalous right coronary artery (RCA) originating from the left coronary artery, he had percutaneous coronary intervention (PCI) to a severe lesion in the left circumflex artery (LCX). The second patient is a 77-year-old male admitted with type 2 NSTEMI. His CT coronary angiogram (CTCA) demonstrated a Lipton Group II SCA with an inter-arterial course; this patient was treated medically. The third patient is a 55-year-old man who was admitted with inferior ST-elevation myocardial infarction (STEMI). The RCA as a possible culprit artery could not be visualized. He had primary PCI to an occluded LCX which continue to supply the RCA (Lipton Group I SCA, congenitally absent RCA). SCA can manifest with a wide range of clinical presentations. And can be very challenging; particularly in STEMI. CTCA has an essential role in providing a definitive diagnosis and anatomical classification in non-urgent presentations. Treatment should be individualized according to presentation and anatomical variation.