Anomalous Coronary Artery Presented with Typical Chest Pain: What is Defi ne The Malignant from Benign Anomalous Coronary Artery (A Case Series)

Background: Congenital coronary anomalies (CCA) are the important causes of morbidity and mortality associated with angina or SCD. CCA divided into two groups, depending on the origin and course of the coronary artery. Malignant CCA comprises arteries with ectopic origin from the contralateral side of the heart followed by an inter-arterial course. Case summary: We presented two distinct characteristics of coronary anomalies with typical chest pain presentation. Both patients had a normal physical examination and no ischemia sign. Coronary CT-angiography showed a malignant type of right anomalous coronary artery from the opposite sinus (R-ACAOS) with an inter-arterial course in case 1. A napkin-ring sign mixed plaque single vessel disease following benign type LCx originating from right coronary sinus anomaly found in case 2. Both patients have different mechanisms causing angina presentation, but both are at high risk of fatal cardiac events. A higher acute coronary syndrome risk and sudden cardiac death were found in patients with the napkin-ring sign, which in case 2 were possibly caused by acute take-off angle features. These supported the term “malignant” caused by inter-arterial course features but followed by several other features. Conclusions: ACAOS is a rare congenital abnormality and not clinically signifi cant, but some have potentially severe symptoms. From the case presented, we could learn that some abnormalities could redefi ne the terms malignantly even in the so-called benign ACAOS. Surgery could be performed besides OMT in reducing the risk of fatal cardiac events and SCD