Background Anomalous aortic origin of a coronary artery is a recognised structural cause of sudden cardiac death in athletes younger than 35 years. Most affected individuals are asymptomatic prior to cardiac events, and resting and exercise electrocardiography (ECG) findings are frequently normal or non‐specific, limiting the effectiveness of preparticipation screening. Case Summary We report a case of a 22‐year‐old asymptomatic athlete in whom preparticipation screening revealed transient ST‐segment depression and T‐wave inversions during submaximal exercise and recovery, whereas findings at peak exercise remained normal. Point‐of‐care echocardiography performed by a sports medicine specialist raised suspicion of an anomalous origin of the right coronary artery from the left aortic sinus of Valsalva, which was subsequently confirmed by computed tomography coronary angiography. High‐risk anatomical features included an acute ostial angle and an interarterial course of the right coronary artery. Functional testing with exercise myocardial stress scintigraphy showed no inducible perfusion defect. Following multidisciplinary consultation, a conservative management strategy with activity modification and close follow‐up was adopted. Discussion This case highlights the potential clinical significance of transient ST–T abnormalities occurring during submaximal exercise and recovery, even in the absence of symptoms or abnormalities at peak workload. In this patient, recognition of this reproducible but non‐specific ECG pattern prompted further structural evaluation leading to the diagnosis of AAOCA. It also underscores the limitations of current guidelines in managing asymptomatic athletes with high‐risk coronary anatomy but without evidence of inducible ischaemia, supporting the need for individualised decision‐making.
Background ST‐segment elevation myocardial infarction (STEMI) in young adults is uncommon and may occur in the absence of significant underlying atherosclerotic coronary artery disease. Recent cannabis consumption has been temporally associated with acute coronary syndromes through several proposed mechanisms, including coronary thrombosis, vasospasm, endothelial dysfunction, and platelet activation. We report two cases of STEMI occurring shortly after cannabis consumption that were managed using a stentless strategy. Case Presentations Case 1: A 36‐year‐old man with recently diagnosed Type 2 diabetes mellitus and a history of daily cannabis use presented with an inferior STEMI approximately 1 h after cannabis consumption. Coronary angiography demonstrated double culprit lesions with thrombotic occlusion of the distal right coronary artery and a large thrombus within the proximal left anterior descending artery without significant underlying angiographic atherosclerosis. A minimalist immediate mechanical intervention (MIMI) strategy consisting of manual thrombus aspiration, dual antiplatelet therapy, and therapeutic anticoagulation was performed, followed by deferred angiographic reassessment after 7 days, which demonstrated complete thrombus resolution and TIMI 3 flow without residual significant stenosis in both vessels. Case 2: A 29‐year‐old man with heavy tobacco use and regular cannabis and alcohol consumption presented with anterior STEMI complicated by acute heart failure. Coronary angiography revealed a high thrombus burden involving the distal left main coronary artery with thrombotic occlusion of the ostial left anterior descending artery. Revascularization was achieved using manual thrombus aspiration, intracoronary glycoprotein IIb/IIIa inhibitor administration, and balloon angioplasty without stent implantation, resulting in restoration of TIMI 3 flow. No significant residual angiographic coronary stenosis was identified. Conclusion These cases illustrate the feasibility of a stentless strategy in carefully selected young patients presenting with a high coronary thrombus burden and no angiographic evidence of significant underlying coronary artery disease. Although a temporal association with cannabis consumption was observed, a causal relationship cannot be established. These observations are hypothesis‐generating, and larger prospective studies are required to better define the mechanisms underlying cannabis‐associated STEMI and the role of stentless management in this setting.
An intercoronary communication is a very rare congenital anomaly characterized by a short connection between two main coronary arteries. A 41-year-old female presented with dyspnea and elevated D-dimer and N-terminal pro brain natriuretic peptide levels. Pulmonary CT angiography demonstrated a pulmonary embolism and significantly enlarged mediastinal lymph nodes. Echocardiography revealed apical akinesia and impaired left ventricular function (ejection fraction of 45%). Coronary angiography showed no evidence of obstructive coronary artery disease but identified an abnormal continuity between the distal right coronary artery and the distal left circumflex artery. Each coronary injection demonstrated retrograde filling of the contralateral artery. The short intercoronary connection did not have the characteristics of an acquired collateral circulation. Cardiac MRI revealed apical akinesia with multifocal areas of subepicardial late gadolinium enhancement raising suspicion for cardiac sarcoidosis. Fewer than 30 cases of intercoronary communication have been reported in the literature to date. This anomaly is often discovered incidentally, as in the present case, and may have a myocardial-protective effect in the presence of coronary artery disease. Conversely, it can also be associated with coronary steal phenomena. However, establishing proof for these mechanisms remains challenging.
Lyme disease may involve the heart during early dissemination and most commonly produces atrioventricular (AV) conduction abnormalities. PR interval prolongation, therefore, frequently guides clinical suspicion and management. We describe a previously healthy man who presented with seizure-like activity, aborted cardiac arrest, transient atrial fibrillation, and cardiac magnetic resonance findings consistent with acute myocarditis, although AV conduction remained normal. Serologic testing subsequently confirmed Lyme carditis. The patient recovered completely with oral doxycycline. This case illustrates that electrical instability may occur despite preserved PR intervals and reinforces the need for suspicion in patients with compatible systemic features.
Cardiac conduction system abnormalities, such as sinus nodal dysfunction and AV block, can lead to significant bradyarrhythmias and pauses, potentially causing symptoms like dizziness and loss of consciousness. Monitoring these rhythm disturbances is crucial, as they may evolve and indicate underlying structural heart disease or lead to more serious arrhythmias. We present the case of a 76-year-old man with an exceptionally prolonged 62-second ventricular pause, followed by a single ventricular beat and an additional 24-second pause before normal rhythm resumes. He presented recurrent, intermittent, and unpredictable episodes of dizziness that were not associated with postural changes. A resting electrocardiogram (ECG) showing a normal sinus rhythm with first-degree heart block prompting placement of the event monitor and that detected the ventricular pauses. To our knowledge, our case represents one of the longest documented ventricular pauses in an ambulatory patient, emphasizing the need for ongoing evaluation in similar cases and the potential benefits of earlier intervention to prevent serious complications and death.
