One for All and All for One

A 76-year-old woman with a history of hypertension and hypercholesterolemia was seen in the outpatient cardiology clinic for atypical chest pain. According to current chronic coronary syndrome guidelines, owing to female sex, age > 70 years, and atypical chest pain, the patient's pretest probability of obstructive coronary artery disease was 19%, and therefore a computed tomography (CT) coronary angiography was performed, which showed a calcium score of 0. The left main (LM) coronary artery was long, hypoplasic, tortuous, and bifurcated in the proximal left auriculoventricular groove into a hypoplasic proximal left circumflex (LCX) and a left anterior descending (LAD) coronary artery with a larger calibre than the LM (Fig. 1A and B). The distal LAD was connected with the posterior descending coronary artery (PDA) (Fig. 1C and D [yellow circle]) at the distal posterior interventricular groove. Furthermore, the posterolateral coronary artery (PLA) was also connected to the distal LCX (Fig. 1C and 1 [green circle]). In spite of this unique coronary artery distribution, there were no significant coronary artery lesions. Although there were no coronary artery obstructions in the CT coronary arteriography, because of the abnormal coronary artery distribution and reduced caliber of the LM, we decided to perform a stress echo test, which ruled out inducible ischemia.