Select Coronary Variant Above

Overview

"Anomalies of coronary arteries are second in frequency among identified structural causes of SCD in competitive athletes, accounting for ≈17% of such deaths in the United States.44 Anomalous origins of coronary arteries from the wrong sinus of Valsalva or from the pulmonary artery are estimated to be present in ≈1% of the overall population45 but are proportionately far more common in athletes who die suddenly, as cited above. Although the vast majority of sudden deaths associated with coronary anomalies occur during or shortly after exercise,46 sudden death has been reported in the sedentary state.47

The most common anomalous origin is the right coronary artery originating from the left sinus of Valsalva, but among athletes who have died suddenly, anomalous origin of the left main or left anterior descending coronary artery from the right sinus of Valsalva is far more prevalent. Furthermore, SCDs are most strongly associated with the pattern in which the anomalous left coronary artery passes between the aorta and main pulmonary artery. An anomalous origin of a coronary artery from the pulmonary artery is far less commonly observed in athletes who die suddenly and in fact often presents with myocardial infarction in infancy or early childhood. Nonetheless, some cases are not recognized until adolescence or adulthood and may be associated with sudden death in athletes, albeit rarely. Nonspecific electrocardiographic findings may be observed in adolescents with otherwise unrecognized anomalous coronary arteries arising from the pulmonary artery.

The ECG is an unreliable screening tool for suspecting or recognizing anomalous origin of coronary arteries before an event, and even stress tests are not uniformly positive among people with these anomalies.48 Clinical symptoms, such as exertional chest discomfort or dyspnea, may be helpful, but 2 reports suggest that 50% of SCDs associated with coronary artery anomalies were first events without prior symptoms.46,49 The best methods for identifying the anomaly include coronary angiography, computed tomography angiography, and magnetic resonance angiography. Although not uniformly successful, athletes undergoing echocardiographic studies for any reason should have careful attempts to identify the origins of the coronary arteries.

Surgical procedures are the only therapies available for correcting these anomalies,50 with return to intense athletic activities permitted after 3 months after the procedure with demonstration of the absence of ischemia on postoperative stress testing.51"