Effective Medical Therapy of Coronary Artery Aneurysms and Ectasia: A Case Report

Technical Summary: Effective Medical Therapy of Coronary Artery Aneurysms and Ectasia

Problem Statement
Coronary artery aneurysm (CAA) and coronary artery ectasia (CAE) are uncommon vascular abnormalities characterized by focal or diffuse dilatation of the coronary vasculature. While often detected incidentally, they are increasingly recognized as clinically significant entities associated with adverse cardiovascular outcomes, including myocardial infarction (MI), thrombosis, and distal embolization. A critical clinical challenge exists in managing patients who present with acute coronary syndrome (ACS) in the absence of obstructive coronary artery disease (CAD). Current management strategies are largely derived from observational evidence and expert opinion due to a lack of randomized clinical trial data and definitive guideline-directed therapy. The pathophysiology in these cases is often attributed to impaired coronary flow dynamics and thrombus formation within the dilated segments rather than fixed luminal obstruction.

Methodology
This study presents a single-case report of a 56-year-old male who presented with persistent retrosternal burning pain. The diagnostic and therapeutic approach followed standard clinical protocols for suspected ACS, adapted for the specific angiographic findings:

• Clinical Assessment: The patient underwent serial high-sensitivity troponin measurements, which rose from 1,748 ng/L to approximately 17,000 ng/L, confirming acute myocardial injury. Electrocardiography showed sinus rhythm with left ventricular hypertrophy but no ischemic ST-segment or T-wave abnormalities.
• Angiographic Evaluation: Coronary angiography was performed to rule out obstructive CAD. The imaging revealed a patent left main artery with mild proximal left anterior descending (LAD) ectasia. Crucially, the left circumflex (LCx) artery exhibited two mid-segment aneurysmal dilatations with an intervening region of slow coronary flow, and the right coronary artery (RCA) was dominant and diffusely ectatic without significant stenosis.
• Therapeutic Intervention: Based on the diagnosis of non-ST-elevation myocardial infarction (NSTEMI) secondary to impaired flow dynamics and thrombosis in the setting of multivessel ectasia, the patient was managed medically. The regimen included anticoagulation (Apixaban), beta-blockade (Carvedilol), high-intensity statin therapy, and an angiotensin receptor blocker (ARB). Aggressive cardiovascular risk-factor modification was also implemented.

Key Results

• Diagnosis: The patient was diagnosed with NSTEMI caused by multivessel coronary ectasia and aneurysmal disease, specifically involving the LCx and RCA, in the absence of flow-limiting atherosclerotic stenosis.
• Clinical Outcome: The patient remained clinically stable throughout hospitalization, with no recurrent chest discomfort prior to discharge.
• Therapeutic Response: The medical management strategy, centered on anticoagulation and risk factor modification, successfully stabilized the patient without the need for invasive revascularization (stenting or surgery), which is often reserved for specific high-risk anatomical scenarios.

Key Contributions
This case report contributes to the existing literature by:

1. Illustrating a Specific Pathophysiology: It provides a concrete example of how impaired coronary hemodynamics and thrombosis within ectatic vessels can precipitate an acute myocardial infarction without obstructive disease.
2. Demonstrating a Medical Management Strategy: It details a successful non-invasive treatment protocol utilizing a combination of non-vitamin K antagonist oral anticoagulants (NOACs), beta-blockers, statins, and ARBs for a patient with multivessel ectasia and NSTEMI.
3. Highlighting Diagnostic Complexity: It underscores the necessity of correlating angiographic findings (slow flow, aneurysmal segments) with clinical presentation to avoid misdiagnosing the etiology of ACS as purely obstructive atherosclerosis.

Significance and Claims
The authors assert that this case highlights the diagnostic and therapeutic challenges inherent in treating acute coronary syndrome in patients with angiographically non-obstructive disease. The primary significance of the report lies in its demonstration that individualized, risk-based medical management is a viable and effective strategy for patients with coronary ectasia in the absence of definitive guideline-directed therapy. The paper emphasizes that while randomized data is lacking, careful selection of anticoagulation and adjunctive medical therapies can manage high-risk presentations. The authors maintain a modest stance, noting that long-term outcome data for this specific patient was not available at the time of writing and that the management approach is guided by observational evidence rather than established randomized trials.