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.