History

Fact Explanation
Asymptomatic Many patients with coronary artery aneurysm (CAA) are asymptomatic. [1]
Chest pain [3] Ischemic chest pain (angina) can occur especially in giant CAAs. This may be due to the fact that most of the CAAs have associated coronary artery stenosis. [4,5]
Dyspnea [3] This is due to congestive cardiac failure. [6]
Palpitations [3] Due to heart failure. [6]
Sudden cardiac death Sudden cardiac death can result due to coronary artery thrombus. This is common in young athletes. [7]
Congenital CAAs can be either congenital or acquired. Congenital CAAs results due to abnormal vascular development. Congenital CAAs are common in right coronary artery. [8,9]
Risk factors for atherosclerotic heart diseases Atherosclerotic coronary vessel disease is the etiology of more than 90% of patients with CAA. Smoking, familial hypercholestrolemia carry an increased risk. [1,4]
History of coronary angioplasty Coronary angioplasty (balloon, atherectomy, laser angioplasty) carries a risk of developing CAA. [1]
History of certain medical conditions Presence of Kawasaki disease, connective tissue disorders (Marfan syndrome, Ehlers-Danlos syndrome), polyarteritis nodosa, Takayasu disease, syphilis and metastatic tumours carries a risk of CAA. [1,3]
Symptoms of myocardial infarction [2] Since most of the CAAs are asymptomatic the initial presentation can be a myocardial infarction. Patients complain of ischemic type retrosternal chest pain which radiates to the left arm, neck and jaw. Myocardial infarction is common complication of left CAAs. [10]
References
  1. GUNDOğDU F, ARSLAN S, BUYUKKAYA E, SENOCAK H. Treatment of a coronary artery aneurysm by use of a covered stent graft - a case report Int J Angiol [online] 2007, 16(1):31-32 [viewed 30 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2733002
  2. ESHTEHARDI P., COOK S., MOAROF I., TRILLER H.-J., WINDECKER S.. Giant Coronary Artery Aneurysm: Imaging Findings Before and After Treatment With a Polytetrafluoroethylene-Covered Stent. Circulation: Cardiovascular Interventions [online] 2008 August, 1(1):85-86 [viewed 30 June 2014] Available from: doi:10.1161/​CIRCINTERVENTIONS.107.763656
  3. EBINA TOSHIAKI, ISHIKAWA YOSHIHIRO, UCHIDA KEIJI, SUZUKI SHINICHI, IMOTO KIYOTAKA, et al. A case of giant coronary artery aneurysm and literature review. Journal of Cardiology [online] 2009 April, 53(2):293-300 [viewed 30 June 2014] Available from: doi:10.1016/j.jjcc.2008.07.015
  4. COHEN PAUL, OʼGARA PATRICK T.. Coronary Artery Aneurysms. Cardiology in Review [online] 2008 November, 16(6):301-304 [viewed 30 June 2014] Available from: doi:10.1097/CRD.0b013e3181852659
  5. BANERJEE P, HOUGHTON T, WALTERS M, KAYE GC. Giant right coronary artery aneurysm presenting as a mediastinal mass Heart [online] 2004 Sep, 90(9):e50 [viewed 30 June 2014] Available from: doi:10.1136/hrt.2002.002519
  6. MCGLINCHEY P. G.. Giant Aneurysm of the Right Coronary Artery Compressing the Right Heart. Circulation [online] 2005 July, 112(4):e66-e67 [viewed 30 June 2014] Available from: doi:10.1161/​CIRCULATIONAHA.104.496224
  7. PONNIAH U. Coronary artery thrombus resulting in sudden cardiac death in an infant with Kawasaki disease and giant coronary artery aneurysms Ann Pediatr Cardiol [online] 2013, 6(2):197-199 [viewed 30 June 2014] Available from: doi:10.4103/0974-2069.115281
  8. SEABRA-GOMES R, SOMERVILLE J, ROSS DN, EMANUEL R, PARKER DJ, WONG M. Congenital coronary artery aneurysms. Br Heart J [online] 1974 Apr, 36(4):329-335 [viewed 30 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1020027
  9. GROB M, KOLB E. Congenital Aneurysm of the Coronary Artery Arch Dis Child [online] 1959 Feb, 34(173):8-13 [viewed 30 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2012450
  10. MAHESHWARI M, TANWAR CP, MITTAL SR. Left Main Coronary Artery Aneurysm: A Rare Presentation Heart Views [online] 2012, 13(2):69-70 [viewed 30 June 2014] Available from: doi:10.4103/1995-705X.99231

Examination

Fact Explanation
None Most CAAs are clinically silent. [1]
Signs of heart failure [1] Peripheral edema, raised jugular venous pressure, cardiomegaly, and pulmonary edema are signs of congestive cardiac failure which is a complication of associated coronary artery fistula.
A murmur In patients with associated coronary artery fistula, a murmur can be audible. [1]
Peripheral stigmata of hypercholestrolemia Atheroma formation is a main etiological risk factor for the development of CAAs. Xanthelasma, xanthomata and corneal arcus are peripheral stigmata of hyperlipidemia. [2,3]
Irregular pulse Arrhythmia can result in irregular pulses. Arrhythmia is common with the involvement of right coronary artery. [5]
Signs of Kawasaki disease Kawasaki disease is one of the common causes of acquired CAAs. Signs of Kawasaki disease include, erythematous skin rash, cracked lips and oral mucosa, strawberry tongue, palpable cervical lymph nodes and fever. [4]
References
  1. EVERETT JEFFREY E, BURKHART HAROLD M. Coronary artery aneurysm: case report. Array [online] 2008 December [viewed 30 June 2014] Available from: doi:10.1186/1749-8090-3-1
  2. PIETROLEONARDO L, RUZICKA T. Skin manifestations in familial heterozygous hypercholesterolemia. Acta Dermatovenerol Alp Pannonica Adriat [online] 2009 Dec, 18(4):183-7 [viewed 30 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/20043058
  3. BANERJEE P, HOUGHTON T, WALTERS M, KAYE GC. Giant right coronary artery aneurysm presenting as a mediastinal mass Heart [online] 2004 Sep, 90(9):e50 [viewed 30 June 2014] Available from: doi:10.1136/hrt.2002.002519
  4. Diagnostic Guidelines for Kawasaki Disease. Circulation [online] 2001 January, 103(2):335-336 [viewed 01 July 2014] Available from: doi:10.1161/​01.CIR.103.2.335
  5. ESHTEHARDI P., COOK S., MOAROF I., TRILLER H.-J., WINDECKER S.. Giant Coronary Artery Aneurysm: Imaging Findings Before and After Treatment With a Polytetrafluoroethylene-Covered Stent. Circulation: Cardiovascular Interventions [online] 2008 August, 1(1):85-86 [viewed 01 July 2014] Available from: doi:10.1161/​CIRCINTERVENTIONS.107.763656

Differential Diagnoses

Fact Explanation
Acute coronary syndrome Chest pain is common in both conditions. Patients complain of constricting type left sided chest pain, which radiates to the left arm and jaw. [3]
Cardiac tumor Giant coronary artery aneurysms may be mistakenly diagnosed as cardiac tumors by the echocardiogram and vice versa. [1]
Mediastinal mass Sometimes cardiac imaging may show aneurysms as mediastinal masses and vice versa. [2]
References
  1. ANFINSEN O, AABERGE L, GEIRAN O, SMITH H, AAKHUS S. Coronary artery aneurysms mimicking cardiac tumor. European Journal of Echocardiography [online] 2004 August, 5(4):308-312 [viewed 30 June 2014] Available from: doi:10.1016/j.euje.2004.02.003
  2. BANERJEE P, HOUGHTON T, WALTERS M, KAYE GC. Giant right coronary artery aneurysm presenting as a mediastinal mass Heart [online] 2004 Sep, 90(9):e50 [viewed 30 June 2014] Available from: doi:10.1136/hrt.2002.002519
  3. KRISTIAN THYGESEN, JOSEPH S. ALPERT, HARVEY D. Universal definition of myocardial infarction. Eur Heart J. [online] 2007; 28 (20): 2525-2538. [viewed 20 June 2014]. Available from: doi: 10.1093/eurheartj/ehm355

Investigations - for Diagnosis

Fact Explanation
ECG Ischemic changes are seen in the ECG. Pathological Q waves can be seen in inferior chest leads (II, III, aVF). [5]
Cardiac enzymes Elevated cardiac enzymes is seen in myocardial infarction. [6]
Coronary angiogram Coronary angiogram can detect the presence of aneurysms by comparing the diameters of the coronary arteries. If dilated vessels' diameters are more than 1.5 times of the adjacent normal coronary arteries an aneurysm is suspected. If the diameter exceeds four times of the normal vessel diameter it is referred to as a giant coronary aneurysm. [1]
Chest CT scan CT scan of the chest is also useful in visualizing the CAAs. When combined with coronary angiogram it will locate the CAA by detecting the dilated coronary vessel. [3,5] The diameter of the CAA can be measured. When combined with angiography CT can detect the CAA with higher sensitivity and specificity.
Echocardiogram Transthoracic echocardiography is frequently used. Transesophageal echocardiogram can be used preferably before the invasive options, when the diagnosis is doubtful. Echocardiography can detect the site of the CAA and the artery of origin. This can be combined with doppler flowmetry. It shows either low or absent blood flow within the CAA. [4]
Cardiac MRI MRI can also demonstrate the presence of CAA by comparing the vessel diameter. Presence of dilated and irregular lumen is also suggestive of a CAA. Thrombi are seen as filling defects within the aneurysmal sac. Cardiac MRI can also assess the motion abnormalities of the myocardium, and also the areas of reversible myocardial ischemia. However cardiac MRI requires more cooperation from the patient and it is time consuming when compared with the CT scan. [4,7]
Thallium scan Thallium scan can identify the areas of reversible myocardial ischemia. This is more sensitive in detecting areas of inducible ischemia than the exercise ECG.
References
  1. GUNDOğDU F, ARSLAN S, BUYUKKAYA E, SENOCAK H. Treatment of a coronary artery aneurysm by use of a covered stent graft - a case report Int J Angiol [online] 2007, 16(1):31-32 [viewed 30 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2733002
  2. ESHTEHARDI P., COOK S., MOAROF I., TRILLER H.-J., WINDECKER S.. Giant Coronary Artery Aneurysm: Imaging Findings Before and After Treatment With a Polytetrafluoroethylene-Covered Stent. Circulation: Cardiovascular Interventions [online] 2008 August, 1(1):85-86 [viewed 30 June 2014] Available from: doi:10.1161/​CIRCINTERVENTIONS.107.763656
  3. EBINA TOSHIAKI, ISHIKAWA YOSHIHIRO, UCHIDA KEIJI, SUZUKI SHINICHI, IMOTO KIYOTAKA, OKUDA JUN, TSUKAHARA KENGO, HIBI KIYOSHI, KOSUGE MASAMI, SUMITA SHINICHI, MOCHIDA YASUYUKI, ISHIKAWA TOSHIYUKI, UCHINO KAZUAKI, UMEMURA SATOSHI, KIMURA KAZUO. A case of giant coronary artery aneurysm and literature review. Journal of Cardiology [online] 2009 April, 53(2):293-300 [viewed 30 June 2014] Available from: doi:10.1016/j.jjcc.2008.07.015
  4. BANERJEE P, HOUGHTON T, WALTERS M, KAYE GC. Giant right coronary artery aneurysm presenting as a mediastinal mass Heart [online] 2004 Sep, 90(9):e50 [viewed 30 June 2014] Available from: doi:10.1136/hrt.2002.002519
  5. NOKUCHI R., KURATA H., HARADA M., AOKI Y., MATSUBARA T., DOI K., ISHII T., GUNSHIN M., HIRUMA T., NAKAJIMA S., YAHAGI N.. Coronary Artery Aneurysms After Adult-Onset Kawasaki Disease. Circulation [online] December, 127(15):1636-1637 [viewed 30 June 2014] Available from: doi:10.1161/​CIRCULATIONAHA.112.130153
  6. LIMA B, VARMA SK, LOWE JE. Nonsurgical Management of Left Main Coronary Artery Aneurysms: Report of 2 Cases and Review of the Literature Tex Heart Inst J [online] 2006, 33(3):376-379 [viewed 01 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1592256
  7. TACKE C. E., KUIPERS I. M., GROENINK M., SPIJKERBOER A. M., KUIJPERS T. W.. Cardiac Magnetic Resonance Imaging for Noninvasive Assessment of Cardiovascular Disease During the Follow-Up of Patients With Kawasaki Disease. Circulation: Cardiovascular Imaging [online] December, 4(6):712-720 [viewed 01 July 2014] Available from: doi:10.1161/​CIRCIMAGING.111.965996

Management - General Measures

Fact Explanation
Health education Patients should be educated about the importance of anticoagulation and or antiplatelet therapy. Regular monitoring of the PT/INR is needed if anticoagulated. Patients should be advised to inform the use of anticoagulation or antiplatelet drugs prior to any surgical procedure. Physical activity is considered safe after the procedure. Patients are advised to get down from the bed and walk around after the procedure, thereafter they can resume daily activities gradually. [1]
Management of heart failure Patients with acute heart failure can be prescribed beta blockers, diuretics, inotropic drugs and angiotensin converting enzyme inhibitors. [2] In addition oxygen is administered either via continuous positive airway pressure (CPAP) or non-invasive positive pressure ventilation (NIPPV). Tracheal intubation may be needed in respiratory muscle fatigue (Type 2 respiratory failure) [3]
References
  1. ROFFI MARCO, WENAWESER PETER, WINDECKER STEPHAN, MEHTA HARESH, EBERLI FRANZ R., SEILER CHRISTIAN, FLEISCH MARTIN, GARACHEMANI ALI, PEDRAZZINI GIOVANNI B., HESS OTTO M., MEIER BERNHARD. Early exercise after coronary stenting is safe. Journal of the American College of Cardiology [online] 2003 November, 42(9):1569-1573 [viewed 30 June 2014] Available from: doi:10.1016/j.jacc.2003.06.006
  2. OSEPH SM, CEDARS AM, EWALD GA, GELTMAN EM, MANN DL. Acute Decompensated Heart Failure: Contemporary Medical Management Tex Heart Inst J [online] 2009, 36(6):510-520 [viewed 30 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2801958
  3. Executive summary of the guidelines on the diagnosis and treatment of acute heart failure: The Task Force on Acute Heart Failure of the European Society of Cardiology. European Heart Journal [online] 2005 January, 26(4):384-416 [viewed 30 June 2014] Available from: doi:10.1093/eurheartj/ehi044

Management - Specific Treatments

Fact Explanation
Stenting Coronary artery stenting with a polytetrafluoroethylene-covered coronary stent a management option for coronary artery aneurysms with the diameter of 6mm to 10mm. [1,2,6]
Surgical therapy Coronary artery bypass grafting is the surgical option of treatment. This can be combined with ligation and resection of the aneurysm. [1,2,6] Ligation of the two ends of the aneurysm and bypass is preferred in aneurysms in the left main coronary artery. [8]
Aspirin For asymptomatic patients with low risk of complications, medical management with low dose aspirin can be recommended. This will minimize the risk of thrombosis, embolism and acute myocardial infarction.[3,5]
Anticoagulation Anticoagulation is recommended treatment option for patients with low risk of aneurysm rupture. Similar to aspirin anticoagulation therapy will minimize the risk of thrombosis, embolism and acute myocardial infarction. [4,5,6]
Conservative management Asymptomatic CAAs can be managed with watchful waiting. [7]
Left ventricular assisted device This is useful in patients with heart failure. [9]
References
  1. GUNDOğDU F, ARSLAN S, BUYUKKAYA E, SENOCAK H. Treatment of a coronary artery aneurysm by use of a covered stent graft - a case report Int J Angiol [online] 2007, 16(1):31-32 [viewed 30 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2733002
  2. ESHTEHARDI P., COOK S., MOAROF I., TRILLER H.-J., WINDECKER S.. Giant Coronary Artery Aneurysm: Imaging Findings Before and After Treatment With a Polytetrafluoroethylene-Covered Stent. Circulation: Cardiovascular Interventions [online] 2008 August, 1(1):85-86 [viewed 30 June 2014] Available from: doi:10.1161/​CIRCINTERVENTIONS.107.763656
  3. EBINA TOSHIAKI, ISHIKAWA YOSHIHIRO, UCHIDA KEIJI, SUZUKI SHINICHI, IMOTO KIYOTAKA, OKUDA JUN, TSUKAHARA KENGO, HIBI KIYOSHI, KOSUGE MASAMI, SUMITA SHINICHI, MOCHIDA YASUYUKI, ISHIKAWA TOSHIYUKI, UCHINO KAZUAKI, UMEMURA SATOSHI, KIMURA KAZUO. A case of giant coronary artery aneurysm and literature review. Journal of Cardiology [online] 2009 April, 53(2):293-300 [viewed 30 June 2014] Available from: doi:10.1016/j.jjcc.2008.07.015
  4. EVERETT JEFFREY E, BURKHART HAROLD M. Coronary artery aneurysm: case report. Array [online] 2008 December [viewed 30 June 2014] Available from: doi:10.1186/1749-8090-3-1
  5. VARDA RAJSEKHAR, CHITIMILLA SANTOSH KUMAR, LALANI ASLAM. Coronary Anomalies: Left Main Coronary Artery Aneurysm. Case Reports in Cardiology [online] 2012 December, 2012:1-3 [viewed 30 June 2014] Available from: doi:10.1155/2012/954951
  6. COHEN PAUL, OʼGARA PATRICK T.. Coronary Artery Aneurysms. Cardiology in Review [online] 2008 November, 16(6):301-304 [viewed 30 June 2014] Available from: doi:10.1097/CRD.0b013e3181852659
  7. BANERJEE P, HOUGHTON T, WALTERS M, KAYE GC. Giant right coronary artery aneurysm presenting as a mediastinal mass Heart [online] 2004 Sep, 90(9):e50 [viewed 30 June 2014] Available from: doi:10.1136/hrt.2002.002519
  8. MAHESHWARI M, TANWAR CP, MITTAL SR. Left Main Coronary Artery Aneurysm: A Rare Presentation Heart Views [online] 2012, 13(2):69-70 [viewed 30 June 2014] Available from: doi:10.4103/1995-705X.99231
  9. GIVERTZ M. M.. Ventricular Assist Devices: Important Information for Patients and Families. Circulation [online] December, 124(12):e305-e311 [viewed 30 June 2014] Available from: doi:10.1161/​CIRCULATIONAHA.111.018226