Acute Coronary Syndrome Secondary to Coronary Artery Aneurysm in an HIV Positive Male: A Case Report Introduction: Coronary artery aneurysms (CAA) are rare and often an unexpected finding on coronary angiography. The most common etiologies are history of Kawasaki disease, atherosclerosis, connective tissue disease and vasculitis. Acute coronary syndrome (ACS) is the most common clinical presentation. Case: A 44-year-old male patient with longstanding history of HIV on medical therapy, presented with a non-ST-elevation myocardial infarction (NSTEMI). He is active at baseline and denied antecedent angina. Angiography was significant for coronary aneurysm in both the left anterior descending and right coronary artery (RCA) with distal thrombotic occlusion of the posterior descending artery. Despite multiple attempts, aspiration thrombectomy was unsuccessful. Patient was discharged with dual antiplatelet therapy. He returned a month later with repeat NSTEMI presentation in the setting of medication non-adherence. Angiography showed ostial RCA thrombotic occlusion. He underwent successful aspiration thrombectomy. He was discharged with both antiplatelet and anticoagulation agents. Further diagnostic evaluation included rheumatologic and infectious lab work that revealed positive ANA and persistently positive rapid plasma reagin despite multiple treatment courses. Of note his HIV is well controlled with an undetectable viral load and CD4 count > 500/ cu mm. Discussion : Given the patient’s ACS, relatively young age, multivessel aneurysmal involvement, and demonstrated medical non-adherence, it is important to understand the etiology and future cardiovascular risk of this anatomy. Current literature suggests coronary aneurysms in HIV positive individuals may be related to accelerated atherosclerosis, increased incidence of inflammatory events, or possibly the virus itself. In this patient, we believe his positive treponemal titers may be contributory as well. Since both his index and subsequent presentations have been ACS rather than angina, serial clinical assessment may not be the best option. We have opted to proceed with a covered stent placement in addition to pharmacotherapy. Conclusion: No consensus guidelines for the management of CAA exist, posing a medical and interventional management dilemma. Further studies are needed to guide management of this uncommon condition.
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