Ting Kevin, Mulukutla Venkatachalam, Franklin Wayne J, Lam Wilson W
Department of Internal Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas.
Department of Internal Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas; Texas Heart Institute, Houston, Texas.
J Emerg Med. 2018 Oct;55(4):e93-e96. doi: 10.1016/j.jemermed.2018.07.015. Epub 2018 Aug 27.
Anomalous coronary artery origins appear in roughly 1% of coronary angiograms, and up to 15% of syncope and sudden cardiac death events can be attributed to anomalous coronaries. Patients with an anomalous coronary artery arising from the opposite sinus may initially present with syncope and electrocardiographic findings of ischemia.
We describe a case in which an adolescent male presented with exercise-induced angina and syncope, and his initial electrocardiogram (ECG) showed diffuse ST-segment depression with ST-segment elevation in lead aVR. Cardiac catheterization revealed there was no coronary ostium in the left coronary cusp, and the left coronary artery had an anomalous origin from the right cusp. The patient received urgent left internal mammary artery-to-left anterior descending artery coronary bypass and a saphenous vein graft to the ramus intermedius. After he underwent 6 months of medical therapy with β-blockade and angiotensin-receptor blockade, his left ventricular systolic function improved to low-normal level (left ventricular ejection fraction, approximately 50%). WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: ST-segment elevation in lead aVR is strongly prognostic for left main or triple-vessel coronary artery disease. However, in patients who present with syncope and few other coronary artery disease risk factors, this ECG finding should be suggestive of an ischemic event caused by an anomalous left coronary artery. Early recognition of this pattern of clinical signs and ECG findings by an emergency physician could be critical for making the correct diagnosis and risk stratifying the patient for early coronary angiography and urgent surgical revascularization.
冠状动脉起源异常在大约1%的冠状动脉造影中出现，高达15%的晕厥和心源性猝死事件可归因于冠状动脉异常。冠状动脉起源于对侧窦的患者最初可能表现为晕厥和缺血性心电图表现。
我们描述了一例青少年男性，表现为运动诱发的心绞痛和晕厥，其初始心电图（ECG）显示广泛的ST段压低，aVR导联ST段抬高。心脏导管检查显示左冠状动脉窦无冠状动脉开口，左冠状动脉起源于右窦异常。患者接受了紧急的左乳内动脉至左前降支冠状动脉搭桥术以及大隐静脉移植至中间支。在接受了6个月的β受体阻滞剂和血管紧张素受体阻滞剂药物治疗后，他的左心室收缩功能改善至低正常水平（左心室射血分数约为50%）。急诊科医生为何应了解此情况？：aVR导联ST段抬高对左主干或三支冠状动脉疾病具有强烈的预后意义。然而，对于表现为晕厥且几乎没有其他冠状动脉疾病危险因素的患者，这一心电图表现应提示由异常左冠状动脉引起的缺血事件。急诊科医生早期识别这种临床体征和心电图表现模式对于做出正确诊断以及对患者进行风险分层以进行早期冠状动脉造影和紧急手术血运重建可能至关重要。
