Challenging differential diagnosis, Rare disease, Congenital defects / diseases
Shahnaz Duymun, Emmanuel Misodi
Department of Medicine, Arnot Ogden Medical Center, Elmira, NY, USA
Am J Case Rep 2020; 21:e923075
Available online: 2020-05-20
Myocardial bridging, although frequent, is often a forgotten cause of angina. It is a congenital anomaly in which the coronary artery tunnels through the myocardium with the overlying muscle, termed a myocardial bridge. The tunneled artery is prone to increased myocardial compression, mechanical load, endothelial damage, and vascular remodeling. During myocardial systole, the tunneled artery undergoes narrowing caused by myocardial compression, which leads to disruption of blood flow, thereby precipitating angina, arrhythmias, infarction, and sudden cardiac death.
CASE REPORT: Here, we present a case of a 29-year-old white woman who presented with atypical left-sided achy chest pain, occurring primarily at rest. Further evaluation showed mildly elevated troponins, with normal electrocardiogram, chest x-ray, and CTA chest. She subsequently underwent coronary angiography and was found to have myocardial bridging of her left anterior descending artery, with compression of up to 40% during systole. She was initially treated with diltiazem, but due to adverse effects was transitioned to metoprolol succinate, which she has tolerated well.
CONCLUSIONS: Myocardial bridging, although benign in nature, carries a vast array of complications requiring these patients to undergo prompt diagnosis and treatment. Vascular spasm, wall stress of the tunneled artery, and intensity of systolic constriction coupled with any delay in management can lead to ischemia, infarction, dysrhythmias, and death. Therefore, it is imperative that patients who have low clinical suspicion for atherosclerosis but who are presenting with anginal equivalents undergo coronary angiography to assess for myocardial bridging and receive immediate treatment.
Keywords: Coronary Angiography, Coronary Vessel Anomalies, Myocardial bridging