Associazione Nazionale Medici Cardiologi Ospedalieri



Coronary artery aneurysm in IgG4-related disease

Mingoia Giulia Palermo(Palermo) – A. O. U. Policlinico Paolo Giaccone | Astuti Giuseppe Palermo(Palermo) – A. O. U. Policlinico Paolo Giaccone | Orlando Emanuele Palermo(Palermo) – A. O. U. Policlinico Paolo Giaccone

Introduction: Coronary artery ectasia is a rare disease defined as a local or diffuse dilatation of the coronary artery more than 1.5 times the diameter of the adiacent normal segment. The etiology is diverse and can be rarely associated with immunoglobulin G4 (IgG4)-related disease. The high levels of serum IgG4 may promote the development of low-density plaques, intimal thickening due to pericoronitis and subsequent coronary ectasia.

Case report: We present the case of a 72-year-old male patient with arterial hypertension, dyslipidemia, chronic renal insufficiency, and a family history of cardiovascular diseases. In the previous year, he suffered a cerebral hemorrhage attributed to an unspecified cerebral vascular malformation, which was managed with an endovascular approach. The patient was admitted for Non-ST-segment Elevation Myocardial Infarction (NSTEMI). Coronary angiography revealed widespread ectasia of the coronary vessels, a chronically occluded marginal branch, and an aneurysmatic proximal right coronary artery with the presence of a thrombus on the aneurysmal segment, dissolved following administration of intracoronaric heparin. Furthermore a critical stenosis at the crux involving the posterior interventricular branch was detected and angioplasty with drug-eluting stent implantation was performed on the affected vessel. Given the coronary artery ectasia, aortic ectasia revealed by echocardiography, renal insufficiency and persistently elevated amylase and lipase levels, further diagnostic investigation was conducted suspecting IgG4-related disease. Hematological tests revealed elevated IgG and IgG4 subclass levels (882 mg/dL and 1438 mg/L, respectively), C3 117 mg/dL, C4 30 mg/dL, and total IgE 130 KU/L. The diagnosis of IgG4-related disease was confirmed and the patient was advised to continue cardiological and rheumatological follow-up.

Conclusion: When the coronary arteries are involved in the IgG4-related disease, risk of acute events such as heart attack may increase and the prognosis is poor. Coronary thickening and ectasia, typical imaging features, other aortic involvement and inflammation indicators, like elevated serum IgG4, should be considered as red flags for an early investigation and subsequent early intervention.