Transient ST–T Changes During Submaximal Exercise Revealing Anomalous Right Coronary Artery Origin in an Asymptomatic Athlete

Background Anomalous aortic origin of a coronary artery is a recognised structural cause of sudden cardiac death in athletes younger than 35 years. Most affected individuals are asymptomatic prior to cardiac events, and resting and exercise electrocardiography (ECG) findings are frequently normal or non‐specific, limiting the effectiveness of preparticipation screening. Case Summary We report a case of a 22‐year‐old asymptomatic athlete in whom preparticipation screening revealed transient ST‐segment depression and T‐wave inversions during submaximal exercise and recovery, whereas findings at peak exercise remained normal. Point‐of‐care echocardiography performed by a sports medicine specialist raised suspicion of an anomalous origin of the right coronary artery from the left aortic sinus of Valsalva, which was subsequently confirmed by computed tomography coronary angiography. High‐risk anatomical features included an acute ostial angle and an interarterial course of the right coronary artery. Functional testing with exercise myocardial stress scintigraphy showed no inducible perfusion defect. Following multidisciplinary consultation, a conservative management strategy with activity modification and close follow‐up was adopted. Discussion This case highlights the potential clinical significance of transient ST–T abnormalities occurring during submaximal exercise and recovery, even in the absence of symptoms or abnormalities at peak workload. In this patient, recognition of this reproducible but non‐specific ECG pattern prompted further structural evaluation leading to the diagnosis of AAOCA. It also underscores the limitations of current guidelines in managing asymptomatic athletes with high‐risk coronary anatomy but without evidence of inducible ischaemia, supporting the need for individualised decision‐making.