Diagnostic considerations in patients with suspected coronary artery anomalies

The diagnosis of coronary artery anomalies requires a high index of suspicion during the history and physical examination. Nonspecific presentations are common, although dramatic presentations such as myocardial infarction or aborted sudden death will occur. Typically the results of the physical examination and ECG and the chest x-ray film are normal except with ALCAPA or coronary-artery fistulas. Screening studies such as exercise stress testing have low sensitivity, and a negative evaluation does not rule out the presence of a significant anomaly. These important limitations must be considered. Echocardiography is a practical and frequently diagnostic test if specific attention is paid to the coronary arteries. This examination should be performed in most patients with suspect symptoms. Other noninvasive techniques such as nuclear and cine MRI cardiac imaging may become increasingly important, but their current use is anecdotal. Cardiac catheterization remains the gold standard; however, recognition of important clues and specific angiographic views are required to fully delineate many anomalies.