Non-Aorto-Ostial Takayasu Arteritis Presenting as Exertional Chest Pain and Syncope Resulting in Coronary Artery Bypass Surgery in a Teenager

Chest pain and syncope are common in adolescents and are usually benign, but they can also be indicative of potentially life-threatening cardiac conditions. We present a rare case of non-aorto-ostial Takayasu arteritis in an adolescent presenting with exertional chest pain and syncope that highlights the importance of considering uncommon diagnoses and conducting comprehensive diagnostic evaluations. The initial diagnostic workup including an ECG and echocardiogram were normal. An ECG stress test demonstrated ST changes consistent with ischemia. Advanced imaging techniques, including cardiac CT and cardiac stress MRI were essential for the accurate diagnosis and management of this patient. Cardiac CT revealed significant wall thickening of the left anterior descending (LAD) artery, consistent with coronary vasculitis, and cardiac stress MRI demonstrated reversible subendocardial ischemia and regional wall motion abnormalities in the LAD distribution. The rheumatologic work-up revealed no additional signs of vasculitis with normal inflammatory markers and unremarkable whole-body MRI. Medical induction therapy with cyclophosphamide and systemic corticosteroids resulted in significant improvement in LAD wall inflammation and thickness. However, the intraluminal LAD diameter remained severely narrowed. Therefore, the patient ultimately underwent coronary artery bypass surgery with a successful outcome and complete resolution of symptoms.