Incidentally Discovered Anomalous Coronary Artery in a Recreational Athlete


A 35-year-old male former competitive swimmer with no past medical history presents for evaluation of an incidentally discovered anomalous right coronary artery from the left coronary sinus. The anomaly was picked up on transthoracic echocardiography done as screening for a bicuspid aortic valve given a recent diagnosis in a family member and he was sent for further imaging. Coronary CTA showed an anomalous dominant right coronary artery from the left coronary sinus with an interarterial course, acute angulated take-off, slit-like orifice and a proximal intramural segment (5 mm).

The patient swam competitively through high school, racing distances of 50-500 meters. After college he started running and has completed several 5-kilometer and 10-kilometer races. He currently runs 25 miles a week with a longest weekly run of 6 miles. He denies any chest pain, shortness of breath, palpitations, presyncope or syncope with or without exertion. He takes no medications or supplements, and denies smoking history, drug use or excessive alcohol use. Family history is unremarkable other than a bicuspid aortic valve in his father. His physical exam and vital signs are normal. He has a normal athlete EKG with right axis deviation <120 degrees and an incomplete right bundle branch block.

He completes a Bruce protocol stress echocardiogram achieving 17 METS and reaching 105% MPHR with no symptoms, EKG changes, arrhythmias or wall motion abnormalities. His cardiac MRI is also normal, with no evidence of scar.

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Which of the following is the best statement/recommendation regarding risk stratification and management of AAOCA?

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