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Coronary artery ectasia with acute myocardial infarction: A case report 1. Dr.Tofayel uddin ahmed, 2. Dr.MD.Tariqul islam khan 3. Dr A.H.M Hasan 4. Dr.Shayla shahadat Abstract Coronary artery ectasia (CAE), a rare condition characterized by abnormal dilation of the coronary arteries, has increasingly been recognized as a potential risk factor for acute myocardial infarction (AMI). While CAE is often asymptomatic, it can predispose individuals to thrombus formation, leading to occlusions and subsequent myocardial damage. Our case is a 36-year-old male with no prior medical problem who presented with chest pain and shortness of breath and was diagnosed as a non-STEMI.The coronary angiogram revealed multiple ectatic segments in the coronary artery with 100% stenosis in the circumflex branch. Coronary artery ectasia represents an emerging risk factor for acute myocardial infarction. The complex relationship between these two conditions is essential for improving diagnosis, prevention, and treatment strategies. Presentation of CAE is usually asymptomatic but when present with occlusive symptoms, management is guided by the extent of occlusion similar to coronary artery disease. Keywords: Coronary artery ectasia, coronary aneurysm, coronary artery disease Introduction: Coronary artery ectasia (CAE) is defined as the abnormal dilatation of the epicardial coronary artery exceeding 1.5 times than the normal adjacent coronary artery [1] Coronary artery ectasia (CAE) was described in 1761 by Morgagni. CAE is an infrequent coronary angiographic finding with a frequency ranging from 1.5% to 5% varied by region.[2-3-4] CAE has clinical presentations and implications similar to CAD, such as stable angina and acute coronary syndrome(ACS) secondary to coronary thrombus formation or vasospasm [5, 6.] The etiology of coronary artery ectasia can be mysterious. Atherosclerosis claims to be the principal etiologic in adults, while Kawasaki disease is the most common cause in children and young adults.[7] 90.8% of patients with CAE were found to have CAD as reported by Swaye et al, [8], and 84.7% of patients in another study [9]. While most patients are asymptomatic, others may present with symptoms of CAD [10]. Here we present a case of a male with CAE who presented with symptoms of non-ST elevation myocardial infarction (NSTEMI) Case presentation: Mr. Sumon, 36 years old, male, non-diabetic, normotensive, smoker, hailing from Sadar Mymensingh, was admitted to this hospital and presented with severe chest pain for 8 hours, which is at the center of the chest. The Patient also complains of shortness of breath, which is more marked on exertion and not relieved by rest. On examination, the pulse was 90 bpm regular blood pressure was 100/70 mmHg respiratory rate was 30 breaths/min, and basal crepitation was present in both lungs. His initial ECG(Fig 1) showed an ischemic change in the inferior and lateral lead. His troponin level was elevated at 9.00 ng/ml (normal level:<0.04ng/l) An echocardiogram showed fair left ventricular function LVEF=53%(Fig 2) with inferior and lateral hypokinesia. The brain natriuretic peptide(BNP) Level was 373 pg/ml (Normal level <100 pg/ml) Liver function test and creatinine were normal. the patient was admitted with a working diagnosis of non-ST segment elevation myocardial infarction (NSTEMI). Coronary angiography showed that the RCA (3.1)– long ectatic vessel in its proximal to distal. LAD(3.2) – Ectatic vessel & 70-80% stenosis in its proximal segment, LCX (3.3)– Total occlusion in its distal segment. PCI is challenging due to the necessity of using large-size devices. the patient was referred to a specialized cardiac center for surgical coronary artery vascularization with coronary artery bypass grafting(CABG) Fig - 1 Inferior and lateral ischemia Fig - 2: Fair left ventricular function Fig - 3.1: RCA Long ectatic vessels proximal to distal FIG 3.2: LAD ectatic vessels and 70-80% proximal stenosis FIG 3.3: LCX total occlusion of the left circumflex distal segment Discussion: The definition of CAE includes dilation of the coronary artery involving a diameter greater than the adjacent normal coronary artery by 1.5 times Based on the morphology and the extent of the coronary arteries’ involvement, we can divide CAE into different groups [11]Classification based on morphology includes the following types: 1. Saccular: the transverse diameter is more than the longitudinal dimension. 2. Fusiform: the transverse diameter is lower than the longitudinal dimension. Classification based on the extent includes the following types: 1. Type 1: diffuse ectasia involving aneurysmal lesions in two vessels 2. Type 2: discrete ectasia in one vessel with diffuse ectasia in another vessel 3. Type 3: one vessel having diffuse ectasia 4. Type 4: one vessel having discrete ectasia In a single observational study involving approximately 5,000 patients, CAE was reported mostly in proximal-mid-RCA (68%), followed by proximal LAD in 60% of cases, and LCX in 50%. Left main coronary artery ectasia (LMCA) is an infrequent occurrence, which accounts for 0.1% of cases [ 12,13] In one study of both children and adults, the most common cause was found to be Kawasaki disease (widespread inflammation of primarily medium-sized muscular arteries) [14].In another study, more than 50% of adult cases were due to atherosclerosis The exact pathophysiology of coronary artery ectasia is unknown. Coronary artery ectasia appears to be exaggerated expansive remodeling of the external elastic membrane resulting in luminal expansion. Enzymatic degradation of the extracellular matrix by matrix metalloproteinases and other lytic enzymes and thinning of the tunica media associated with severe chronic inflammation is the principal pathogenesis of expansive remodeling.[15 ] CAE is also related to apical hypertrophic cardiomyopathy with high wall tension. In iatrogenic mechanisms, eg, percutaneous coronary interventions, including balloon angioplasty, stent placement, and atherectomy, can lead to the formation of aneurysms or ectasias. The mechanism is the injury of the media of the blood vessel.[16] In general, males are more prone to CAE than females, and the biggest risk factor is hypertension. A low incidence of CAE has been found in diabetic patients. This could be attributed to negative remodeling and matrix metalloproteinases(MMP) downregulation in response to atherosclerosis [17]. The habit of smoking has been associated with patients suffering from CAE than patients with CAD. Regardless of smoking, another independent predictor of CAE is cocaine use [18]. Coronary angiography is the gold standard procedure for diagnosing CAE. The disturbances in washout and blood flow filling related to the severity of ectasia can be shown with the help of angiography. The local dye deposition in the dilated coronary segment and the segmental backflow phenomenon known as delayed antegrade dye filling are the signs of stagnant and turbulent flow signs indicated in angiography [19,20]. Nowadays, CAE can be diagnosed with the help of other modalities such as coronary CT angiogram (CTA) and coronary magnetic resonance angiogram (MRA) [21] In designing a treatment plan for patients with CAE, all risk factors must be taken into consideration along with the coexisting diseases. Treatment is directed towards risk reduction (management of atherosclerosis and hypertension management of CAD and obstructive lesions if found; thus, treatment can include medical, angioplasty, and surgical modalities [22,23] Percutaneous coronary intervention (PCI) can be used for patients with obstructive CAD with CAE when medical treatment fails [24] Our patient was treated with medical therapy as non-ST elevated MI. After one month CAG was done and diagnosed with triple vessel disease. As PCI is challenging due to the necessity of using large-size devices, we can choose surgical coronary artery vascularization with coronary artery bypass grafting(CABG). As Surgery is another option for CAE and the indications are similar to those for patients with CAD It may also be a better option for large aneurysms. [25] [26] Conclusion: CAE is an uncommon condition CAE may present with the classic symptoms of AMI, including chest pain, dyspnea, diaphoresis, and nausea. The precise mechanisms underlying CAE-associated AMI are not fully understood. The diagnosis of CAE in patients with AMI can be challenging, Coronary angiography is often required to visualize the ectatic segments of the coronary arteries. The management of CAE-associated AMI is generally similar to that of AMI. Further research is necessary to elucidate the underlying mechanisms and develop targeted therapeutic approaches for patients with CAE-associated AMI. REFERENCES [1] E. Pinar Bermudez et al.Coronary ectasia: prevalence, and clinical and angiographic characteristics Rev Esp Cardiol (2003) [2]. Lazzarin P, Pasero G, Marson P, Cecchetto A, Zanchin G. Takayasu’s arteritis. 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