Myocardial Ischemia Caused by Paroxysmal Supraventricular Tachycardia in a Patient with Anomalous Origin of Right Coronary Artery Arising from Left Sinus of Valsalva
A 58-year-old man presented with chest pain and palpitation for 2 hours at rest. He had no previous chest pain or palpitation. He had 40-pack-year smoking and daily alcoholic drink. On admission his blood pressure was 130/90 mm Hg, pulse rate 196 beats per minute, respiratory rate 20 per minute and body temperature 36.6℃. The electrocardiogram showed PSVT with pulse rate 190 bpm (). The patient was treated with adenosine 6 mg twice and his symptoms subsided. Follow-up electrocardiography displayed ST change and T inversion in leads II, III, aVF and V 4-6 (). Blood pressure was 150/100 mm Hg with heart rate of 80 bpm. Cardiac enzyme showed transient increase; creatine kinase-MB 5.8 ng/mL (normal <5 ng/mL), myoglobin 154 ng/mL (normal <110 ng/mL), troponin T 0.3 ng/mL (normal <0.1 ng/mL). He had no other abnormal laboratory findings. Echocardiogram exhibited preserved left ventricle (LV) systolic function and concentric LV hypertrophy. But mild hypokinesia in septum and anterior wall of LV was noted. He was diagnosed with PSVT and temporary acute myocardial injury. After the acute episode terminated, he was treated with aspirin, lipid lowering agent, angiotension II receptor blocker and intravenous heparin. We performed multidetector computed tomography. Coronary CT angiography revealed that the RCA arose from the left sinus of Valsalva with acute angle of the ostium and course between the right ventricular outflow tract and the aorta ( and ). Other intracoronary atherosclerotic lesion was not observed. The treadmill test was done with good exercise performance and the result showed ST depression in leads III, aVF. 24 hours holter monitoring showed one episode of non-sustained ventricular tachycardia for 0.8 seconds. We continued medical treatment including ATII receptor blocker, bisoprolol and aspirin and recommended life style modification.