Critical ostial left main and right coronary artery stenosis secondary to takayasu arteritis in a young female simulating pulmonary embolism at presentation

A 28-year-old Caucasian female presented to the Emergency Department (ED) with sudden-onset chest pain. Thirty-six hours earlier, she was diagnosed with a pulmonary embolism, for which anticoagulation was started. Evaluation was significant for atrial fibrillation, elevated cardiac biomarkers, and echocardiography demonstrating a new wall motion abnormality. Symptoms resolved with spontaneous conversion to normal sinus rhythm and the patient was initiated on intravenous heparin and eptifibatide, followed by admission. Shortly after admission, the patient experienced recurrent chest pain with dynamic electrocardiographic (ECG) changes that prompted emergent cardiac catheterization. Prior to angiography, the patient developed pulseless cardiac arrest for which advanced cardiac lifesaving (ACLS) techniques were initiated. Coronary angiography showed critical ostial stenosis of the left main coronary artery. Despite transient periods of hemodynamic stability after successful stenting, the patient decompensated and was pronounced dead. Postmortem findings were consistent with Takayasu arteritis (TA). TA involving the coronary arteries is rare, presenting in fewer than 5% of cases. Diagnosis relies heavily on clinical suspicion. For our patient, dynamic ECG changes with wall motion abnormalities visible on echocardiography prompted diagnostic/therapeutic cardiac catheterization and stenting. Management involves high-dose systemic steroid therapy. However, due to recurrence of disease and adverse effects of prolonged steroid use, additional disease-modifying agents such as methotrexate, azathioprine, or cyclophosphamide may be used. With appropriate therapy, short-term prognosis is favorable. This case underlines the importance of having a high clinical suspicion for TA in the young female population with ischemic symptoms in order to allow early diagnosis in hopes of preventing further complications.