title: Chest pain with diffuse coronary ischaemia.
abstract: An 80-year-old male with a medical history of hypertension, diabetes and moderate calcific aortic stenosis, presented with ischaemic chest pain at rest. Cardiovascular examination revealed soft systolic murmur only. ECG (see online supplementary figure S1) demonstrated inferolateral ST segment depression with ST elevation in lead aVR, suggesting diffuse subendocardial ischaemia possibly consistent with a threatening left main or proximal left anterior descending (LAD) coronary lesion. Emergency coronary angiography demonstrated tandem smooth stenoses in the proximal left circumflex (LCx) and LAD arteries (figure 1A), which persisted throughout the cardiac cycle, and after 200 mcg bolus of intracoronary nitrate. Aortogram is shown (figure 1B).
  
  
  
  What diagnosis underlies the cause of this patient's symptoms? Congenital coronary artery anomaly.Coronary artery vasospasm.Myocardial bridging.Obstructive coronary artery disease.Unruptured left sinus of Valsalva aneurysm.
authors.affiliation: Department of Cardiology, John Radcliffe Hospital, Oxford, UK.
authors.forename: A
authors.initials: A
authors.lastname: Apps
authors.affiliation: Department of Cardiology, High Wycombe Hospital, High Wycombe, Buckinghamshire, UK.
authors.forename: A
authors.initials: A
authors.lastname: Sinha
authors.affiliation: Department of Cardiology, High Wycombe Hospital, High Wycombe, Buckinghamshire, UK.
authors.forename: A
authors.initials: A
authors.lastname: Money-Kyrle
mesh_terms: D000369:Aged, 80 and over; D000787:Angina Pectoris / Q000000981:diagnostic imaging / Q000209:etiology*; D001014:Aortic Aneurysm / Q000150:complications* / Q000000981:diagnostic imaging / Q000503:physiopathology; D001027:Aortography / Q000379:methods; D002302:Cardiac Output; D000072226:Computed Tomography Angiography; D017023:Coronary Angiography; D003326:Coronary Circulation; D023921:Coronary Stenosis / Q000000981:diagnostic imaging / Q000209:etiology* / Q000503:physiopathology; D017809:Fatal Outcome; D006801:Humans; D008297:Male; D012850:Sinus of Valsalva / Q000000981:diagnostic imaging / Q000503:physiopathology