Coronary artery anomalies are congenital defects which are found incidentally or after cardiac events. While these are rare abnormalities with the majority of patients remain asymptomatic and largely undiagnosed, it remains to be a major cause of sudden cardiac death (SCD). Anomalous origin of left coronary artery (ALCA) from the opposite right aortic sinus is extremely rare with less than 100 cases reported to-date. These patients are at increased risk for significant cardiac events, including SCD. In this report, we present a 48-year-old man with hypertension and marijuana use who was admitted initially with multi-lobar pneumonia and acute kidney injury, developed respiratory failure and sustained ST elevation myocardial infarction (STEMI). Coronary angiography demonstrated anomalous origin of all three main coronary arteries arising from right aortic sinus. In this report we also discuss the genesis of this rare and potentially fatal congenital abnormality and we highlight the diagnostic and management strategies available to-date.
Marijuana is the most widely used recreational drug across the United States. Ongoing efforts to legalize marijuana, as well as the drug's increasing popularity contribute to the marijuana's reputation as having a low risk profile. Marijuana's association with adverse cardiovascular events, such as arrhythmia and vasospasm is welldocumented. We synthesized what is known about how marijuana use pertains to and is implicated endothelial cell damage and its effects on microcirculation. THC exerts effects through the cannabinoid receptors, CB1 and CB2. The downstream effects of CB1 activation point to a role for this receptor in atherogenesis and vasospasm, likely by precipitating oxidative stress. Endothelial cells, when exposed to reactive oxygen species, provide a stimulus for vasoconstriction with a diminished ability for vasodilation. This phenomenon has manifested itself in cases of coronary vasospastic angina, and coronary slow and no flow that have resulted from marijuana use, as confirmed by cardiac catheterization reports that showed no evidence of obstructive lesions that could otherwise be responsible for the patients' symptoms. Marijuana users suffer from acute ischemic stroke at higher rates than non-users. Several theories have been proposed to support this observation, namely marijuana induced reversible cerebral vasoconstriction syndrome, and mitochondrial damage caused by oxidative stress that disproportionately affects cerebral vasculature. As marijuana use continues to grow, so does the important of elucidating the drug's effect on endothelial cells and microcirculation. Further studies should investigate the temporal association between marijuana and endothelial damage, as well as the possibility of recovery from such injury, and whether there is therapeutic potential in cannabinoid receptors.
Introduction: Anomalous origin of coronary arteries has a prevalence of 1% in the population and is independently associated with a risk of sudden cardiac death. While an anomalous coronary artery arising from the opposite sinus is rare, all three coronary arteries arising from separate ostia in a single cusp is an extremely rare phenomenon. Case: A 48-year-old male with history of hypertension presented with fevers, cough and shortness of breath of 3 days duration. CXR demonstrated multi-lobar pneumonia and serology returned positive for Influenza A. Treatment was initiated with oseltamivir, vancomycin and piperacillin-tazobactam. Subcutaneous heparin was initiated for VTE prophylaxis. On day 3, the patient developed acute hypoxic respiratory failure from flash pulmonary edema necessitating intubation and mechanical ventilation. ECG revealed ST segment elevation in leads II, III, aVF, V5 and V6 (Fig. 1A). He was taken for urgent cardiac catheterization. Coronary angiography revealed anomalous origins of the left circumflex (LCX) and left anterior descending (LAD) arteries arising from the right coronary cusp (RCC) (Fig. 1B & 1C). 99% thrombotic occlusion of the distal right coronary artery was identified as the culprit lesion (Fig 1D). Percutaneous coronary intervention with a 4 x 30 mm drug-eluting stent was performed. Discussion: Absence of the left coronary artery originating from the left coronary sinus should raise suspicion for a coronary anomaly. While an anomalous LCX artery originating from the RCC is seen in 0.7% individuals, the LAD artery arises from the RCC is seen in 0.15% of people. All three coronary arteries arising from the RCC is extremely rare. An abnormal take-off angle, compression between the aorta and the pulmonary trunk, slit-like ostia, coronary hypoplasia and accelerated atherosclerosis are responsible for the increased risk of coronary events in this population.
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