A 43-Year-Old Ultramarathon Runner with Chest Pain
A 43-year-old male ultra-marathon runner presented to the emergency department (ED) with complaints of chest pain. Symptoms occurred one hour into a training run on the day of presentation. Past medical history was significant for hyperlipidemia treated with rosuvastatin 40 mg daily. The patient had a computed tomography coronary calcium score 1-year prior with an Agatston score of 167 Hounsfield units. Family history was significant for sudden cardiac death in an uncle around 40 years of age. On arrival to the ED, he was given sublingual nitroglycerin which provided symptom relief. Vital signs were stable. Cardiac auscultation was unremarkable other than a faint, 1/6 continuous murmur heard in the right and left upper sternal border. Laboratory results revealed an initial troponin T of 147 ng/L (normal ≤15 ng/L) which decreased 2 hours later to 132 ng/L. Complete blood counts and renal function were unremarkable. Electrocardiogram (ECG) revealed a first-degree AV block and an early repolarization pattern (Figure 1). Chest X-ray was unremarkable.
He was diagnosed with non-ST segment elevation myocardial infarction (NSTEMI) and the decision was made to proceed with coronary angiography.
Coronary angiography revealed balanced dominance with moderate, diffuse coronary artery atherosclerosis with the most significant stenosis involving the proximal left anterior descending (LAD) artery. The artery appeared 50% obstructed and the instantaneous wave-free ratio assessment of the lesion revealed a ratio of 0.96 (normal >0.9). There were likely two coronary artery fistulas (CAF) arising from the proximal LAD (Figure 2A) and conus branch of the right coronary artery (RCA) (Figure 2B) which emptied into the main pulmonary artery (PA).
To further characterize CAF anatomy, a cardiac computed tomography angiogram (CTA) was obtained the following day. This revealed a ring like connection between the LAD and conus branch of the RCA which met to form a focal saccular aneurysm measuring 9 mm that fistulized to the main PA (Figure 3A-B). The PA caliber was in normal limits. Cardiac chamber size was normal. Agatston score was 186 Hounsfield units and left ventricular ejection fraction (LVEF) 70%.
What is the next best step in this patient's management?