Hospital Pedro Hispano; Centro Hospitalar de S. João.

INTRODUCTION: Coronary artery ectasia (CAE) is a rare condition (incidence ranging between 0.2% and 10% on patients undergoing coronary angiograms), defined as a diffuse dilation of a coronary artery exceeding 1.5 times the adjacent normal coronary artery. Its underlying etiology is not fully understood. Atherosclerosis is responsible for 50% of cases and in the great majority of these patients ectasia coexists with coronary artery disease. About 10-20% of CAE cases are associated with inflammatory or connective tissue diseases. Iatrogenic aneurism formation after balloon angioplasty and infections are rare causes of CAE. CEA can present with angina, myocardial infarction, arrhythmia or sudden death. The main recognized mechanism is the slow coronary blood flow observed in ectasic coronaries angiograms that is thought to promote thrombus formation.
CLINICAL CASE: We present a 65-year-old man with previous myocardial infarction without ST elevation eight years before, who presented to the emergency department with typical chest pain. Initial electrocardiogram showed a biphasic T wave in leads V3 and V4, flat T wave in V5, DII and aVF and a symmetric inverted T wave in DIII. High-sensitivity troponin value was 194 ng/L at admission. An acute coronary syndrome was admitted and a coronary angiography was performed, revealing a left coronary artery with diffuse ectasia and a right dominant coronary artery also with diffuse ectasia and a thrombus on its middle and distal segments. No stent was implanted and he was treated with dual antiplatelet therapy and anticoagulation for a week. After that a new angiography showed significant reduction of thrombotic burden. We prolonged triple therapy for one more week and after that the patient was discharged with dual antiplatelet therapy. No recurrent symptoms were noticed until now. Consulting hospital records we found that the previous myocardial infarction was also due to a thrombus on the same site of the ectasic right coronary artery.
DISCUSSION: It is known that patients with CAE who suffered a myocardial infarction have higher risk of recurrence than those without CAE. There is no consensus about CAE treatment and secondary prophylaxis of ischemic events. There is some evidence that both antiplatelet and anticoagulant agents can be used. Coronary angioplasty with stent implantation can be challenging and also problematic. In this case we successfully treated our patient with two weeks of triple therapy followed by dual antiplatelet therapy.