SHM Converge Scientific Abstract ePoster Gallery-Caught in a Red and Blue Squeeze: A Plaque-Free Coronary Crisis

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A 44-year-old woman with newly diagnosed hypertension and obesity presented with syncope shortly after taking her first dose of nifedipine. She had nausea, diaphoresis, tachycardia, new-onset atrial fibrillation with rapid ventricular response, and mildly elevated troponin, but no chest pain or known coronary disease. Initial evaluation showed normal electrolytes, thyroid studies, chest X-ray, and normal left ventricular function on echocardiogram.<br /><br />Because of concern for ischemia, coronary CT angiography was performed and revealed a congenital anomaly of the right coronary artery (RCA). The RCA originated abnormally and followed an interarterial course between the aorta and pulmonary artery, with high-grade narrowing from dynamic compression. No obstructive atherosclerotic coronary artery disease was present. Cardiac catheterization confirmed the absence of plaque and difficulty selectively engaging the anomalous RCA. Cardiothoracic surgery was consulted and recommended surgical correction, such as unroofing, translocation/reimplantation, or bypass.<br /><br />This case highlights a rare but important “malignant” coronary anomaly, which can cause transient ischemia, arrhythmias, syncope, and sudden cardiac death, especially when the vessel is compressed during exertion or hemodynamic stress. The authors suggest nifedipine may have worsened ischemia through vasodilation and coronary steal, reducing perfusion to the affected territory and contributing to syncope and arrhythmia.<br /><br />Key teaching points are that myocardial ischemia in a young or low-risk patient without coronary plaque should prompt evaluation for structural coronary anomalies, and that vasodilators like dihydropyridine calcium channel blockers should be used cautiously when such anomalies are suspected. Early recognition and surgical management are critical to reduce mortality risk and improve long-term outcomes.

Asset Subtitle

Zoya Khan

Meta Tag

Author List Anas Bizanti, Jennifer Trube, Michael Sabina, Sophia Elortegui, Zoya Khan

Category Clinical Vignettes

Concept Anomalous Coronary Artery Origin

Concept Inter-arterial Course

Concept Myocardial Ischemia

Concept Sickle Cell Disease

Concept Anomalous Right Coronary Artery

Distinguished Non-Finalist

Presenter Organization Lakeland Regional Health

Presenting Author Zoya Khan

Track Adult

Keywords

hypertension

obesity

syncope

nifedipine

atrial fibrillation

troponin elevation

coronary artery anomaly

interarterial course

right coronary artery

myocardial ischemia

Anomalous Coronary Artery Origin

Inter-arterial Course

Myocardial Ischemia

Sickle Cell Disease

Anomalous Right Coronary Artery