Anomalous Right Coronary Artery in Stress Cardiomyopathy: Coincidental or Contributory?

We report a case of a 72-year-old female with no known comorbidities who presented with dizziness and dyspnea while exercising on a treadmill. Upon presentation in the hospital, she became hemodynamically unstable with multiple episodes of retching and vomiting, eventually intubated for airway protection. Electrocardiogram revealed minimal ST elevation in the lateral leads which prompted performance of coronary angiography that revealed mild luminal irregularities but noted to have an anomalous right coronary artery. Left ventriculography demonstrated severe left ventricular dysfunction with apical ballooning. Echocardiogram showed dynamic left ventricular outflow obstruction with an ejection fraction of fifteen percent. The patient was aggressively managed including administration of inotropes, then gradually transitioned to cautious initiation of beta blockers, angiotensin converting enzyme inhibitor, and aldosterone antagonist. Transthoracic echocardiogram and cardiac magnetic resonance imaging two weeks later showed improved ejection fraction of forty to fifty five percent respectively. The patient denied syncope, angina, or exertional dyspnea on subsequent health maintenance evaluation.