A 33-year-old man with atypical chest pain

Abstract

Clinical introduction: A 33-year-old man with no history of coronary artery disease presented to the rapid access cardiology clinic with an episode of atypical anginal chest pain. He had a 15 pack-year history of smoking and a family history of myocardial infarction under the age of 55. Physical examination and exercise ECG testing were unremarkable. On assessment in the cardiology clinic, blood sampling was notable for an elevated high-sensitivity troponin I of 61 ng/L (99% upper reference level, 34 ng/L). A coronary CT angiogram was performed (figure 1).

Question: Which of the following best explains this presentation? MyocarditisMyocardial bridgingKawasaki's diseaseAtherosclerotic plaque ruptureEosinophilic coronary monoarteritis.

Figure 1

CT multiplanar reformatting of the left anterior descending artery with vessel wall analysis of a proximal (blue) and distal (red) segment.

Figure 2

(A) Coronary CT angiography of left anterior descending artery (LAD) with non-calcified plaque proximal to first diagonal bifurcation. The arrow points to the culprit plaque in the proximal LAD on the Coronary CT angiogram. (B) Invasive coronary angiogram demonstrated complete occlusion of the proximal LAD. (C) Percutaneous coronary intervention at the site of plaque rupture restored coronary blood flow.