A 77-year-old male presenting with NSTEMI was diagnosed with triple vessel coronary artery aneurysms and managed medically with NOAC and GDMT.
Case Report (n=1)
This case highlights the diagnostic and therapeutic challenges of managing NSTEMI caused by triple vessel coronary aneurysms rather than obstructive atherosclerosis.
Abstract Introduction Coronary artery aneurysms (CAA) are uncommon findings, identified in approximately 0.3-5% of patients undergoing coronary angiography. Their etiology is multifactorial, often related to atherosclerosis, previous percutaneous coronary interventions, or inflammatory conditions. Although most cases remain asymptomatic, CAAs can predispose to thrombus formation, distal embolization, or rupture, posing significant management challenges. This case report describes a rare presentation of triple vessel coronary aneurysms in a patient with known coronary artery disease and heart failure with reduced ejection fraction, emphasizing the diagnostic and therapeutic dilemmas inherent to this condition. Description A 77-year-old male with a past medical history of CAD status post STEMI with PCI and stent placement 10 years prior, and heart failure with reduced ejection fraction (EF 42% before presentation), presented with new onset midsternal chest pressure (8/10), non radiating, without associated dyspnea, palpitations, or diaphoresis. On arrival, the EKG demonstrated sinus rhythm with frequent PVCs, ST-T depressions in inferior and anterolateral leads, and Q waves in lead III. Serial high ensitivity troponins trended upwards (279, 445, 725 ng/L). The patient was treated for NSTEMI; initiated on heparin infusion and aspirin, with a plan for cardiac catheterization. Coronary angiography revealed triple vessel coronary artery aneurysms, most pronounced in the LAD and left circumflex, with distal tapering, and a chronic total occlusion (CTO) of the RCA. No obstructive lesions warranting intervention were found. ECHO showed an LVEF of 30% and extensive myocardial scarring. Surgical revascularization was deferred and deemed unlikely to provide benefit by cardiothoracic surgery team, given the chronic total occlusion of the right coronary artery and changes seen on echocardiogram. The patient was medically managed with NOAC and GDMT with close monitoring. Discussion Management remains challenging and individualized, particularly in cases without flow limiting stenosis. CABG is typically reserved for obstructive disease or giant aneurysms at high risk of rupture, whereas medical therapy focusing on thrombosis prevention is preferred when ischemia arises from distal embolization rather than fixed obstruction. In this patient, the coexistence of multivessel aneurysms, reduced systolic function, and a prior CTO created a complex therapeutic landscape. The decision to pursue anticoagulation rather than revascularization highlights the delicate balance between the ischemic risk from thrombus formation and distal embolization, and the hemorrhagic risk associated with systemic anticoagulation. This case underscores the clinical importance of recognizing coronary aneurysms as a potential etiology of ischemic symptoms. This abstract is funded by: None
Yepez et al. (Fri,) conducted a case report in Coronary artery aneurysms (n=1). Medical management (NOAC and GDMT) was evaluated. A 77-year-old male presenting with NSTEMI was diagnosed with triple vessel coronary artery aneurysms and managed medically with NOAC and GDMT.