A Coronary Artery Anomaly Presenting as Acute Coronary Syndrome: A Case Report.

BACKGROUND Coronary artery anomalies (CAAs) are rare congenital malformations with different clinical presentations and pathophysiological mechanisms. These anomalies are frequently the cause of sudden death in young patients. Most CAAs are incidental findings owing to the lack of symptoms; however, they may be associated with acute coronary syndrome in rare cases. CASE REPORT We describe the case of a 47-year-old man who presented with a 1-day history of progressive typical chest pain and elevated troponin levels. The patient underwent a coronary angiography, which unveiled the anomalous origin of the left main coronary artery arising from the right coronary artery, with an interarterial course between the ascending aorta and the pulmonary artery, without coronary artery disease. Coronary computed tomography angiography confirmed the CAA and its relationship with the symptoms. An uneventful coronary artery bypass graft was undertaken, and at the 1-year follow-up, the patient was asymptomatic, with a normal stress test. CONCLUSIONS This case depicts the presentation of atypical acute coronary syndrome in a young patient with a rare CAA. In such patients, coronary angiography and coronary computed tomography angiography are essential tools to confirm the diagnosis and to determine treatment. Although controversial, in young individuals presenting CAA with an interarterial course, such as the left main coronary artery arising from the right coronary artery, coronary artery bypass graft may be an important treatment option to avoid sudden death in the future.

Clinical outcomes and need for intensive care after non-ST-segment-elevation myocardial infarction.

BACKGROUND: The decision on whether non-ST-segment elevation myocardial infarction (NSTEMI) patients should be admitted to intensive care units (ICU) takes into account several factors including hospital routines. The Acute Coronary Treatment and Intervention Outcomes Network (ACTION) ICU score was developed to predict complications requiring ICU care post-NSTEMI. METHODS: We described patient characteristics and clinical outcomes of 1263 NSTEMI patients admitted to a private hospital in Sao Paulo, Brazil, from 2014 to 2018. We also aimed to retrospectively identify NSTEMI patients who might not have needed to be admitted to the ICU based on the ACTION ICU risk score. We defined complications requiring ICU care post-NSTEMI as cardiac arrest, cardiogenic shock, stroke, re-infarction, death, heart block requiring pacemaker placement, respiratory failure, or sepsis. RESULTS: Mean age was 62.3 years and 35.8% were female. A total of 94.6% of NSTEMI patients were admitted to the ICU. Most NSTEMI patients (91.9%) underwent coronary angiography. Percutaneous coronary intervention was performed in 47.1% and coronary artery bypass graft surgery in 10.3%. Complications requiring ICU care occurred in 62 patients (4.9%). In-hospital mortality rate was 1.3%. Overall, 70.4% had an ACTION ICU score ≤ 5. The C-statistics for the ACTION risk score to predict complications was 0.55 (95% confidence interval 0.47-0.63). CONCLUSIONS: Complications requiring ICU care were infrequent in a cohort of NSTEMI patients who were routinely admitted to the ICU over a 4-year period. The ACTION risk score had low accuracy in the prediction of complications requiring ICU care in our population.