Case Presentation
A 56-year-old gentleman, a smoker and a known case of hypertension,
presented to our department with the acute onset of retrosternal chest
pain. The patient was in his usual state of health when he suddenly
started enduring pain while watching television 1 hour before his
presentation to the emergency department. According to the patient, it
was crushing in quality, 8/10 in intensity, and non-radiating. The pain
was accompanied by nausea and diaphoresis. Prior to this episode, the
patient had no history of similar pain or acute coronary syndrome.
On examination, the patient was hemodynamically stable with a heart rate
of 88 beats/min and blood pressure of 154/88 mm of Hg. His ECG
delineated ST elevation in leads II, III, aVF, V4, V5, and V6, while ST
depression was noted in ECG leads I, aVL, V2, and V3 (Figure 1).
Laboratory results showed a WBC count of 4.7 B/L, haemoglobin of 12.6
g/dL, haematocrit of 38.1%, platelet count of 206 B/L, sodium level of
142 mmol/L, BUN 20 mg/dL, protein 6 g/dL, creatinine of 0.91 mg/dl,
total bilirubin 0.5 mg/dL, ALP 48 IU/L, AST 13 IU/L and pro- BNP 215
pg/mL.Additionally, troponin I level was substantially elevated to over
8000 ng/l, boosting a solid suspicion of myocardial infarction. Hence,
the patient was immediately administered 324 mg of Aspirin and 400 mcg
of Nitro-glycerine sublingually, along with 80 mg of Atorvastatin and
Heparin infusion. He was taken for urgent catheterization, which
revealed a large RCA aneurysm, ectatic LAD, and LCX without any
elemental obstructive lesion (Figure 2). Furthermore, a CT angiogram of
coronary arteries demonstrated a giant RCA aneurysm filled with a
thrombus leading to compression of the right atrium and effacement of
superior vena cava (Figure 3).
Besides, his distal RCA was also dilated with curvilinear calcification
in its wall. In addition to the above findings on performing a
transthoracic echocardiogram, his ejection fraction was 50% with
inferior wall hypokinesis. Therefore, the patient was evaluated by the
cardiothoracic surgery team, who elected to perform an imperative
surgery for resection of the aneurysm and bypass grafting of RCA. Upon
surgery, the size of proximal RCA was documented to be 81 by 78 mm.
After the surgery patient was started on 25 mg of Metoprolol daily.