Introduction: Coronary artery anomalies (CAA) are congenital anomalies that affect the coronary vessel origin, their anatomy and histologic structure with the prevalence in the general population between 0.5-2%. The most common subgroup of CAA are the anomalies of the vessel origin and direction. Most patients are asymptomatic for a large portion of their lives, although the first clinical symptom may be sudden death. There are 3 treatment options: medical treatment/observation, coronary angioplasty with stent deployment, and surgical repair. (1-3) We report a patient with anomalous origin of the left coronary artery (LCA) who presented with chest pain and was treated conservatively.

Case report: 71-years-old female arrived at the Emergency Department complaining of an intermittent retrosternal chest pain and dyspnea during the last 7 days. Her blood pressure was also higher for the last 7 days, up to 200 mmHg in systole. She performed an unremarkable exercise testing and a nuclear stress testing which showed inferolateral, posterolateral, apicoseptal and inferoposterior hypoperfusion. The physical examination was unremarkable. ECG showed sinus bradycardia with ventricular premature beats. She was prescribed a bisoprolol, trimetazidine, nitrate, amlodipine, statin and aspirin. Six months later, she performed coronary angiography which showed an anomalous origin of LCA from the right Valsalva sinus. She was referred to a MSCT coronarography which confirmed the finding. RCA was free of pathomorphologic changes. ACx was a dominant artery, while LAD was gracile, without stenotic lesions. On follow-up visit after three months, the patient was free of chest pain. The last follow-up visit was three years later, and the patient is still asymptomatic.

Conclusion: The main finding of this case report consisted of a LCA emerging from the right Valsalva sinus without anomalous features of other coronary arteries. The elderly patient presented with atypical chest pain and was treated conservatively, with a combination of beta-blocker and anti-ischemic agents, trimetazidine and nitrate, in order to provide the decompression of the vessel between aorta and pulmonary artery.