Jamal Fares, Waqas Shamaiza, Skovira Vincent, Sayed Luay
Department of Cardiology, Ascension Macomb-Oakland Hospital, Warren, MI, USA.
Department of Internal Medicine, Ascension Macomb-Oakland Hospital, Warren, MI, USA.
AME Case Rep. 2024 Jun 25;8:75. doi: 10.21037/acr-23-190. eCollection 2024.
Anomalous right coronary artery from pulmonary artery (ARCAPA) is one of four known anomalies of the coronary arteries originating from the pulmonary artery. ARCAPA is a rare congenital anomaly that is associated with possible long-term complications including myocardial ischemia and left ventricular dysfunction. Clinical presentation can vary from asymptomatic murmur to angina, dyspnea, fatigue, congestive heart failure, myocardial infarction and even cardiac arrest.
We present a case of a 52-year-old male who presented to the hospital for intermittent chest pain. The patient was vitally stable and examination was unremarkable. Upon workup, electrocardiogram (EKG) on admission showed no acute ischemic changes and troponin were <0.03 ng/mL. The patient was evaluated by cardiology and had a dobutamine stress echocardiogram (ECHO) for ischemic evaluation. During the recovery phase of dobutamine stress ECHO, the patient reported having 10/10 chest pain with a drop in blood pressure to 90 mmHg systolic. He was subsequently given sublingual nitroglycerin and fluids. Pain did resolve and blood pressure improved after treatment. No wall motion abnormalities were noted on ECHO, but there were inferior ST depressions on EKG during the stress portion of the test. The patient had repeated blood work after the stress test which showed an elevated troponin level of 0.08 ng/mL. The patient was taken to the catheterization lab for diagnostic coronary angiogram. Cardiac catheterization showed a right coronary artery (RCA) arising from the pulmonary artery and diagnosis of isolated ARCAPA was made because of his intermittent chest pain. No intervention was performed as no significant lesions were found. The patient was started on medical therapy including aspirin, beta blocker and statin. The patient did not want to pursue surgery at that point and he did not want any further intervention. He was discharged home with instructions to follow up with cardiology in an outpatient setting to be referred for surgical repair.
The purpose of writing this case is to increase awareness among physicians to be able to recognize possible anomalous coronary artery origins during cardiac catheterization and to understand the risk of long-term complications of ARCAPA and need for surgical repair.
起源于肺动脉的异常右冠状动脉（ARCAPA）是已知的四种起源于肺动脉的冠状动脉异常之一。ARCAPA是一种罕见的先天性异常，可能伴有包括心肌缺血和左心室功能障碍在内的长期并发症。临床表现从无症状杂音到心绞痛、呼吸困难、疲劳、充血性心力衰竭、心肌梗死甚至心脏骤停不等。
我们报告一例52岁男性患者，因间歇性胸痛入院。患者生命体征稳定，检查无异常。检查时，入院心电图（EKG）显示无急性缺血改变，肌钙蛋白<0.03 ng/mL。患者由心脏病学专家评估，并进行了多巴酚丁胺负荷超声心动图（ECHO）以评估缺血情况。在多巴酚丁胺负荷ECHO的恢复阶段，患者报告胸痛程度为10分（满分10分），收缩压降至90 mmHg。随后给予他舌下含服硝酸甘油和补液。治疗后疼痛缓解，血压改善。ECHO未发现室壁运动异常，但在试验的负荷部分EKG显示下壁ST段压低。负荷试验后患者多次进行血液检查，显示肌钙蛋白水平升高至0.08 ng/mL。患者被送往心导管实验室进行诊断性冠状动脉造影。心脏导管检查显示右冠状动脉（RCA）起源于肺动脉，由于其间歇性胸痛，诊断为孤立性ARCAPA。由于未发现明显病变，未进行干预。患者开始接受包括阿司匹林、β受体阻滞剂和他汀类药物在内的药物治疗。患者当时不想接受手术，也不想进行任何进一步的干预。他出院回家，并被告知在门诊随访心脏病学专家，以便转诊进行手术修复。
撰写本病例的目的是提高医生的认识，使其能够在心脏导管检查期间识别可能的冠状动脉异常起源，并了解ARCAPA的长期并发症风险以及手术修复的必要性。
