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Isolated coronary artery aneurysms presenting with ST-elevation myocardial infarction – a case of when less is more

Introduction Coronary aneurysms are defined as a localized dilatation that can be saccular (transverse larger than the longitudinal axis) or fusiform (longitudinal at least twice the transverse axis). This is a distinct entity from coronary artery ectasia, in which there is diffuse dilatation involving greater than half of the coronary artery. Coronary artery aneurysm (CAA) formation has been described in the literature as early as 1761 by Morgagni [1]. The incidence of CAAs reported in different observational series ranges from 0.9 to 4.9% [2,3]. However, the management of patients presenting with acute myocardial infarction (AMI) in this setting remains a quandary and is subject to limited clinical evidence. This case provides a further anecdote in the management of aneurysm-related AMI. Case report A 57-year-old lady presented to our hospital with cardiac chest pain at rest for the preceding 4 h. Her ECG showed ST-segment elevation and q-waves in the inferior leads (Fig. 1). In view of her continuing pain, emergency angiography was performed and showed aneurysmal left and right coronary systems, with the infarct-related artery being a large aneurysmal right coronary artery (RCA) with significant thrombus burden, and TIMI-1 antegrade flow (Fig. 2). Percutaneous revascularization was not undertaken in view of the anatomical nature of the RCA, and the patient was therefore managed medically. Echocardiography showed severe hypokinesis of the inferior lateral wall, thrombus within the RCA, and an ejection fraction of 40% (Fig. 3). Haematological and biochemical assessments were negative for autoimmune or systemic disorders. A computed tomography angiogram, performed to determine whether there was evidence of widespread vascular aneurysm formation, reaffirmed aneurysmal coronary arteries but no other regions of aneurysm formation (Fig. 4). The patient was prescribed with 12 months of clopidogrel, lifelong warfarin bridged with low molecular weight heparin, in addition to β-blocker, angiotensinconverting-enzyme inhibitor, high-dose statin and aldosterone antagonist therapy. She remains well 12 months after her index event, with no angina and no