Why fear can be fatal?

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A 51-year-old previously healthy woman collapsed after experiencing chest pain. The chest pain was preceded by severe emotional distress following a fire in her neighborhood. This event caused extreme anxiety in the patient. Physicians at the scene found a conscious patient and prepared transport her to the medical center. An electrocardiogram obtained in the ambulance revealed extensive anterior ST-segment elevation. During transport, the patient became unconscious and pulseless. The medics immediately performed a successful defibrillation and brought the patient to the emergency service of our center. The patient underwent emergency coronary angiography, which demonstrated an anomalous left main coronary artery (LMCA) arising from the right sinus of Valsalva (Fig. 1a). The right coronary artery (RCA) arose from the appropriate sinus but a different origin (Fig. 1b). LMCA, left circumflex and left anterior descending artery appeared to be angiographically normal. Because of the potential high-risk of sudden cardiac death in patients with an anomalous LMCA, we felt it was prudent to completely define the route of the LMCA in relation to the great vessels, as an inter-arterial course between the aortic root and pulmonary artery would warrant surgical intervention. For that purpose, a 64-slice multidetector computed tomography (MDCT) coronary angiography was performed to further evaluate the coronary anatomy and to determine the course of the anomalous LMCA. MDCT was performed using an Aquilion device (Toshiba Medical, Tokyo, Japan) and volume rendering and axial images were obtained. The LMCA coursed between the aortic root and main pulmonary artery and gave off the left anterior descending and left circumflex arteries in their normal position (Fig. 2). The RCA system was nondominant without significant stenosis. Because of the high risk of sudden cardiac death and the patient's history, she underwent surgical re-implantation of the anomalous LMCA to the left coronary sinus.

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