One Ostium, Multiple Risks: A Single Coronary Origin Presenting as Acute Coronary Syndrome

Coronary artery anomalies are uncommon congenital variations of the coronary anatomy that can remain undiagnosed yet pose a significant risk of potentially fatal cardiovascular events, such as myocardial infarction (MI).Among them, the single coronary artery (SCA) anomalywhere all coronary vessels originate from a single ostium-is particularly rare and clinically challenging.We present the case of a patient with a solitary coronary ostium in the left sinus of Valsalva, presenting with acute coronary syndrome (ACS).This is a rare yet potentially lifethreatening congenital coronary anomaly.A 68-year-old male patient presented at the emergency department two hours after experiencing severe chest pain.His medical history was significant for diabetes mellitus, hypertension, and active smoking.The preliminary physical examination revealed a blood pressure of 105/75 mmHg, a heart rate of 92 bpm, a respiratory rate of 25 breaths per minute, and an oxygen saturation of 95%.Cardiac auscultation was unremarkable and revealed normal heart sounds without murmurs.Importantly, the initial electrocardiogram (ECG) demonstrated sinus rhythm at 76 bpm with pronounced ST-segment depressions in leads DII, aVF, and V3-V6, indicating significant myocardial ischemia (Figure 1).The patient was immediately diagnosed with non-ST elevation MI and was urgently hospitalized to the intensive care unit and administered a loading dose of 5000 IU unfractionated heparin and 300 mg acetylsalicylic acid.Subsequent coronary angiography revealed a unique coronary architecture in which all coronary arteries originated from a single trunk anomalously from the right-anterior sinus of Valsalva (Figure 2).Notably, several significant coronary artery stenoses were identified, including a 50% stenosis in the left main coronary artery, a 40% stenosis in the proximal left anterior descending artery, a 50% stenosis in the first obtuse marginal artery, and an 80% stenosis in the circumflex artery.Additionally, a critical near-total occlusion (99%) was detected at the ostium of the right coronary artery (RCA), along with diffuse