A 43-Year-Old Ultramarathon Runner with Chest Pain

Jul 23, 2021   |  Robyn Bryde, MD; Brian Shapiro, MD; Andrew Bowman, MD; Matthew W. Martinez, MD, FACC
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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.

Figure 1

Figure 1
Figure 1. ECG on arrival to the emergency department.

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).

Figure 2A

Figure 2A
Figure 2A. Coronary angiogram image demonstrates an arcade of abnormal vessels arising from the LAD artery, coalescing into an abnormal pre-pulmonic vessel (arrowhead) that terminates in an aneurysm (*). A thin jet of contrast extends posteriorly from the aneurysm (small arrows) into the unopacified PA, confirming a fistulous communication. LCx = Left circumflex artery.

Figure 2B

Figure 2B
Figure 2B. Coronary angiogram with evidence of a CAF (arrow) which extends from the conus branch (arrowhead) of the RCA.

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%.

Figure 3A

Figure 3A
Figure 3A. Volume-rendered CT image shows a small pre-pulmonic aneurysm (*) fed by abnormal arterial branches from the LAD (arrowhead) and conus branch of the right coronary artery (arrows), completing the ring of Vieussens.

Figure 3B

Figure 3B
Figure 3B. Oblique coronal coronary CT image shows the small pre-pulmonic aneurysm seen in Figure 3A with a small fistula to the PA (arrow), similar to that seen in Figure 2A. Abnormal vessel communicating the aneurysm from the LAD is seen inferior to the aneurysm (arrowhead). Ao = Aorta.

What is the next best step in this patient's management?

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