Case Report An unexpected cause of angina detected by ECG-gated cardiac computed tomography Mylonas Ilias, Claudius Mahr, John Salanitri, Robert Edelman & Andrew Hamilton Department of Medicine, Evanston Northwestern Healthcare, Evanston Hospital, 2650 Ridge Avenue, Evanston, IL, 60201, USA Received 14 August 2005; accepted in revised form 19 August 2005 Key words: anomalous, computed tomography, RCA Abstract Until recently anomalous coronary artery anatomy was only identified either by coronary angiography, at autopsy, or during cardiac surgery. With recent developments in the area of cardiac imaging, ECG-gated cardiac computed tomography (CT) has emerged as a minimally invasive modality to delineate both coronary anatomy and pathology. We present a case of an anomalous right coronary artery origin from the ascending aorta detected by ECG-gated cardiac CT in a 47 year-old male who presented to the emergency department complaining of acute chest pain after intense exercise. Given its relatively non invasive nature, ECG-gated cardiac CT may assist in the diagnosis and management of patients with atypical chest pain in which more invasive diagnostic examinations (i.e. coronary angiography) are not warranted. Case report A 47 year old Caucasian male presented to the emergency department of our institution with complaints of chest pain that began immediately after high level exercise and intensified upon entering a hot-tub shortly thereafter. He described the pain as central chest ‘‘tightness and heat’’. The pain did not radiate and was associated with pal- pitations, nausea, light-headedness, and shortness of breath. Aspirin was administered on arrival in the emergency department. An electrocardiogram (ECG) obtained immediately upon arrival revealed sinus rhythm without evidence of ischemia. The patient declined sublingual nitroglycerine and the pain gradually subsided one and one half hours after its onset. Further history revealed that he had previously experienced less severe episodes of pain occurring with exercise over many years. Review of systems was essentially unremarkable as was his past medical and surgical history. He denied any family history of coronary artery disease (CAD) and had been a non smoker all his life and occa- sionally indulged in alcoholic beverages. A com- plete blood cell count and basic chemistry panel were all normal. First and second sets of troponin I blood levels (drawn 6 h apart) were both 0.01 ng/ dl and a chest x-ray taken was normal. The patient consented to an investigational study using ECG gated multidetector computed tomography (MDCT) for evaluation of chest pain in patients who presented to the emergency department who were low or intermediate risk for acute coronary syndrome (ACS). ECG-gated The International Journal of Cardiovascular Imaging (2006) 22: 287–293 Ó Springer 2005 DOI 10.1007/s10554-005-9026-y