Exercise-Induced Ventricular Tachycardia Unmasking High-Risk Anomalous Right Coronary Artery in an Adult

BACKGROUND: Anomalous aortic origin of a coronary artery (AAOCA) is a rare congenital anomaly associated with myocardial ischemia, ventricular arrhythmias, and sudden cardiac death. Although typically identified in younger individuals, it may present in adulthood with nonspecific or exercise-related symptoms. CASE SUMMARY: A 43-year-old physically active man with no prior cardiac symptoms presented with intermittent dizziness and palpitations. Exercise stress testing demonstrated frequent ventricular ectopy progressing to nonsustained ventricular tachycardia during recovery. Coronary computed tomography angiography (CCTA) revealed an anomalous right coronary artery arising from the left sinotubular junction with an interarterial and intramural course. He underwent surgical unroofing with resolution of symptoms on follow-up. DISCUSSION: AAOCA should be considered in adults presenting with exercise-related ventricular arrhythmias, particularly during stress test recovery. Prompt anatomical evaluation with CCTA enables early identification of high-risk anatomy and timely surgical intervention with favorable outcomes. TAKE-HOME MESSAGES: AAOCA can present in adulthood with exercise-related ventricular arrhythmia despite normal cardiac structure. CCTA is essential for identifying high-risk anatomical features, while management decisions should integrate both anatomy and clinical evidence of ischemia or arrhythmia.