Unusual Revelation of an Anomalous Right Coronary Artery: Non-ST Segment Elevation Myocardial Infarction (NSTEMI) in the Context of Drug Abuse

Coronary artery anomalies (CAAs) are rare congenital abnormalities. Certain variants, such as those with an intramural course, are associated with increased risk of ischemia and sudden cardiac death, particularly under conditions of increased cardiac demand. We report the case of a 36-year-old male with polysubstance abuse who presented with chest pain after cocaine intake. Initial labs, testing, and imaging revealed respiratory failure, hypoxia, elevated cardiac biomarkers, and new-onset reduced ejection fraction. After the patient was medically stabilized, coronary computed tomography angiography was performed, which revealed an anomalous right coronary artery (RCA) originating from the left coronary cusp with a malignant intramural course and significant stenosis. The patient was then discharged and later underwent successful surgical marsupialization of the RCA into the aorta with cardiothoracic surgery. His postoperative recovery was uncomplicated, and he was discharged with close follow-up. In this case, it is likely that cocaine-induced vasospasm exacerbated the anomaly, leading to the non-ST segment elevation myocardial infarction. This case demonstrates the importance of considering coronary anomalies in young patients with chest pain and no traditional risk factors, particularly in the setting of stimulant use. Early detection and surgical intervention are critical to prevent sudden cardiac death, and multidisciplinary care is essential for long-term success.