An Unusual Cause of Diffuse T-Wave Inversion: Coronary Arteriovenous Fistula

Coronary artery fistulas (CAFs) are rare congenital or acquired coronary anomalies, most often identified incidentally on cardiac imaging, with a wide spectrum of clinical presentations.

A 33-year-old man presented with recurrent angina and ventricular tachycardia. His evaluation was notable for diffuse T-wave inversion across the limb and precordial leads in sinus rhythm on surface 12-lead electrocardiogram (ECG) and the presence of a CAF on coronary angiography. He was diagnosed with ventricular tachycardia secondary to coronary steal syndrome and was successfully managed with surgical fistula resection.

This case illustrates the diagnostic challenges and management considerations of CAF in a patient presenting with chest pain, ventricular tachycardia, and diffuse T-wave inversion on ECG.

Diffuse T-wave inversion in the limb and precordial leads represents repolarization abnormality. Large CAF causing coronary steal syndrome should be considered in the differential diagnosis of chest pain, ventricular arrhythmias, and diffuse T-wave inversion on ECG.