Working Diagnosis:
Anomalous (Malignant) origin of the right coronary artery

Treatment:
This patient was placed on full activity restriction to include no lifting greater than 10 lbs. and no physical exertion greater than light desk work pending definitive surgical management by cardiothoracic surgery. Patient subsequently underwent right coronary artery unroofing procedure, with repeat CCTA demonstrating resolution of malignant coronary track.

Outcome:
Following definitive surgical care, patient underwent aggressive cardiac rehabilitation for 3 months with gradual increase in aerobic exercise load. At her 3-month post-surgical mark, patient underwent repeat CCTA demonstrating full resolution of her malignant coronary track and was returned to full duty status with her Army unit without restriction.

Author's Comments:
This case presents a rare cause of presyncope, chest pain, and possible sudden cardiac death in young physically active adults. Coronary artery anomalies are a rare anatomic finding, seen in less than 1% of the general public (Ferreira 2019, Gentile 2021) with 80% being asymptomatic. However, these findings account for the second highest rate of sudden cardiac death in young athletes (Maron 2009). Specific screening guidelines for coronary artery anomalies do not currently exist. Diagnostic testing for these coronary artery anomalies includes several options ranging from exertional echocardiography to invasive angiography (Gentile 2021, Zeppilli 2023). When evaluating an athlete with exertional chest pain, presyncope or other evidence of ischemic injury- the gold standard diagnostic test is coronary computed tomography angiography (Gentile 2021, Zeppilli 2023).

Editor's Comments:
This case highlights the importance of thoroughly evaluating an athlete (or active individual) when the symptom patterns are exertional. This patient’s history (recent similar episodes) and abnormalities on EKG appropriately prompted additional consultation and advanced imaging. The importance of protecting the athlete from harm while work up was under way (eg. activity or duty restriction in this case) and involving relevant specialists is further illustrated in this case.
Additionally, this case helps remind primary care sports physicians to review all lifestyle and risk factors in a patient/athlete’s history. In the context of whole athlete care, counseling to abstain from vaping nicotine for this patient is individually important, but more broadly for all athletes to avoid nicotine use, in any format vaping, etc. Emerging work continues to highlight the risks of nicotine and vaping in active individuals (Bains 2024).

References:
Bains, S, et al. Temporal Association Between Vaping and Risk of Cardiac Events, Mayo Clin Proc 2024 Feb;99(2):241-248.
Ferreira, A. FP, Rosemberg S, Oliveira DS, Araujo-Filho, J AB, and Nomura, CH (2019). Anomalous origin of coronary arteries with an interarterial course: pictorial essay. Radiologia Brasileira, 52(3), 193–197

Gentile, Francesco, et al. “Coronary artery anomalies.” Circulation, vol. 144, no. 12, 21 Sept. 2021, pp. 983–996

Maron BJ, Doerer JJ, Haas TS, Tierney DM, Mueller FO. Sudden deaths in young competitive athletes: analysis of 1866 deaths in the United States, 1980-2006. Circulation. 2009; 119:1085–1092

Zeppilli P, Bianco M, Gervasi SF, Cammarano M, Monti R, Sollazzo F, Modica G, Morra L, Nifosì FM, Palmieri V. Congenital coronary artery anomalies in sports medicine. Why to know them. Clin Cardiol. 2023 Sep 46(9):1038-1048

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