Syncope toolkit

Syncope is very common and will affect 42% of people during their lifetime

Anomalous origin of left coronary artery in a child with syncope

History

A normally fit and well 12 year boy, with no significant past medical history developed shortness of breath during sports lessons at school. There was no significant medical history, he took no medication and there was no family history of cardiac disease or sudden death.

Examination

An ECG, FBC and U+E were normal

What would you do next?

You would refer him to a paediatrician to further evaluate his symptoms,

What happened next?

He was referred to a paediatrician with an interest in cardiology. He was investigated with an exercise treadmill test, which was normal.

2 years later, age 14, he developed syncope during a football match. An emergency ambulance was called and assessment by the paramedics revealed he was in ventricular fibrillation. He was successfully resuscitated with cardioversion and transferred to hospital for further assessment. ECG showed normal sinus rhythm with no ischaemic changes.

He went on to have an echocardiogram which revealed anomalous origin of the left anterior descending artery. This was confirmed on coronary angiography and repaired surgically.

Learning Points

  • Anomalous origin of a coronary artery due to obstruction in its path or flow abnormalities, is associated with an increased risk of myocardial ischaemic during exercise and subsequent ventricular arrhythmias. It is the third most frequent cardiac cause of deaths associated with exercise among athletes aged 12-35 years
  • Almost 50% of patients report symptoms including syncope, chest pain, and breathlessness prior to sudden death
  • Coronary abnormalities are amongst the most common congenital cardiovascular anomalies, surpassing in prevalence nearly all others combined. Many congenital coronary abnormalities have a benign outcome
  • Anomalous origin of the left coronary artery cannot be excluded by normal ECG and normal exercise treadmill tests
  • Echocardiography is a key investigation when assessing young patients with syncope or chest pain associated with exercise.