A 45-year-old man with a history of dyslipidaemia and familial coronary artery disease was referred to our institution for increasing episodes of exertional chest pain over the past weeks. Previous cardiac stress testing on a bicycle ergometer revealed non-specific ST abnormalities (180 W, heart rate ranging from 65–169 beats/min, stopped because of leg pain). The results of clinical examination and an electrocardiogram were normal, and the troponin I concentration was in the normal range. Echocardiography showed normal left ventricular ejection fraction with no wall-motion abnormalities. Coronary angiography revealed right-dominant circulation with no coronary stenosis. A congenital anomalous origin of the right coronary artery was seen, with the origin in the left coronary sinus close to the left main artery ( Fig. 1 ). The patient underwent 16-slice coronary computed tomography (CT), which showed a right coronary artery origin from the left coronary sinus, with an interarterial course between the ascending aorta and the pulmonary trunk ( Fig. 2 ). Betablocker therapy was initiated in the absence of sudden cardiac death, ventricular arrhythmia or exercise-induced presyncope. With treatment, the patient had no symptoms and the results of the nuclear stress test were normal, with no myocardial ischaemia (150 W, heart rate from 55–145 beats/min, stopped because of stiffness) ( Fig. 3 ). A conservative management approach was decided, without surgical correction.
