Anomalous origin of the right coronary artery from the pulmonary artery: Adult clinical insights

Anomalous origin of the right coronary artery from the pulmonary artery (ARCAPA) is a rare congenital coronary anomaly affecting approximately 0.002% of the population. This case report describes an adult male presenting with exertional chest pain and dyspnea, ultimately diagnosed with ARCAPA. Unlike its left-sided counterpart (anomalous origin of the left coronary artery from the pulmonary artery), ARCAPA is typically not fatal in infancy or childhood but can lead to various clinical manifestations, including sudden cardiac death. A 30-year-old male patient presented with a 3 month history of exertional chest pain and dyspnea. Initial investigations, including electrocardiography, cardiac markers, and echocardiography, were normal. However, an exercise stress test was positive, with the patient experiencing symptoms during Stage 2 of the Bruce protocol. Coronary angiography revealed retrograde filling of the right coronary artery from the left coronary arteries, suggesting an anomalous origin from the pulmonary artery. Cardiac computed tomography confirmed the diagnosis of ARCAPA and also showing compression of the right coronary artery’s origin between the aorta and main pulmonary artery. This case highlights the importance of considering congenital anomalies in the differential diagnosis of angina, especially in younger patients. Despite often being asymptomatic, ARCAPA carries a risk of sudden cardiac death, emphasizing the need for thorough investigation and management. Current guidelines recommend surgical intervention for all individuals diagnosed with ARCAPA, regardless of symptom status. However, the patient in this case declined surgical correction and is being managed medically with close follow-up.