Unusual Presentation of Obstructive Atherosclerotic Coronary Artery Disease With Chronic, Persistent Neck and Shoulder Pain: A Case Report.

Ischaemic chest pain or its equivalents are acute-onset in acute coronary syndrome (ACS) and chronic, episodic, and transient in chronic coronary syndrome (CCS). A 56-year-old Caucasian male with a history of premature atherosclerotic coronary artery disease (CAD) presented to secondary care with recurrent presyncope and syncope. He reported a year-long history of persistent left-sided neck and shoulder dull ache/tightness, unrelated to exertion and fluctuating unpredictably. His primary care had diagnosed the pain as musculoskeletal, attributing it to prior physical trauma. However, the pain did not respond to treatment. During his admission for suspected cardiac syncope, he experienced transient chest discomfort, transient inferior ST-segment elevation on electrocardiogram (ECG), and elevated troponin levels, indicating a non-ST-elevation myocardial infarction (NSTEMI). Coronary angiography revealed obstructive atherosclerotic two-vessel disease, with severe proximal stenosis in the right coronary artery (RCA) and moderate-to-severe stenosis in the left anterior descending artery (LAD). His chronic neck and shoulder pain resolved after percutaneous coronary intervention (PCI) with drug-eluting stent (DES) placement in the RCA, confirming it was an anginal equivalent. Although the chronicity of this anginal equivalent may align it more with CCS than ACS, its unremitting nature is inconsistent with CCS. Our patient's history also showed that his ischaemic symptoms changed over time, from remote exertional dyspnoea to persistent neck and shoulder pain, and then to the chest discomfort that preceded his NSTEMI. Our case highlights the importance of heightened clinician awareness of atypical CAD presentations and symptom variability over time. Symptoms initially considered non-anginal should be reassessed for CAD, particularly when alternative treatments prove ineffective. Similar cases like ours, in the future, could prompt updates to CCS diagnostic guidelines to address atypical presentations with persistent pain.