Introduction: Single coronary artery is a rare conge-nital abnormality, with a prevalence of 0.024-0.066%. These cases make up less than 3% of all congenital co-ronary anomalies. Although benign variants exist, so-metimes aberrant vessel courses can lead to myocardi-al ischemia and risk of sudden death. Patients with a single coronary artery and cardiovascular risk factors have the same likelihood of developing atherosclerotic disease.

Methods: A 64 year old patient presented to the emer-gency room with anterior chest pain characteristic of angina pectoris, accompanied by nausea and vomiting. Smoking and dyslipidemia were noted as cardiovascu-lar risk factors. Based on the clinical presentation and non-invasive investigations, an acute coronary syndro-me is presumed.

Results: Electrocardiographic recording revealed si-nus rhythm with minimal ST depression in the inferior leads. Serum myocardial necrosis marker values were suggestive of a myocardial infarction. Transthoracic echocardiography showed undilated cardiac chambers and a left ventricle with preserved systolic function and no regional wall motion abnormalities. Coronary an-giography is performed and reveals a single coronary artery originating in the right coronary sinus, which trifurcates at its origin into a dominant right coronary artery, an anterior interventricular artery and a circumflex artery. The lesion presumed to be responsible  for the myocardial necrosis is a subocclusion of a small branch originating in the proximal anterior interventricular artery. For a better description of the course of the three vessels a CT coronary angiogram was also performed.

Conclusions: Literature on the association of single coronary artery and acute coronary syndrome is limited to only a few case reports and patient series. Interventional and surgical coronary revascularisation is described in these patients. For our patient we opted for optimal medical treatment as the main epicardial coronary arteries were without any significant lesions, with the only critical stenosis situated on a small branch.