• Congenital Heart Defects
• Coronary Atherosclerotic Disease
• Coronary vessels
• Myocardial ischemia
• Sudden Cardiac Death

Background: Anomalous origins of coronary arteries (AOCAs) are a cause of sudden cardiac death in young athletes. With the widespread use of coronary computed tomography angiography (CCTA) for suspected coronary atherosclerotic disease (CAD), AOCAs are increasingly identified in older patients. This study evaluates their clinical and prognostic implications in a large adult cohort undergoing CCTA.
Methods: Consecutive adults with AOCAs identified on CCTA were included. Baseline anatomical and clinical characteristics were retrieved, including clinical presentation, AOCA subtype, high-risk features, myocardial ischemia, and coexisting CAD. Patients were followed up for death and major adverse cardiac events (MACE, i.e., acute coronary syndromes, revascularizations, and heart failure), and outcomes were compared with matched controls with normal coronary anatomy.
Results: Among 17,454 CCTAs performed over 20 years, 174 patients with AOCAs (aged 62 ± 15 years) were identified. Chest pain (34%) and arrhythmic symptoms (33%) were the most common indications for CCTA. Obstructive CAD was present in 21% (n=36), while myocardial ischemia in 60% of those undergoing functional imaging (n=37/62). AOCA repair was performed in 6% (n=10) following detection. After a median 37-month (17-69 months) follow-up, death (p=0.474) and MACE (p=0.149) rates were similar between AOCA patients and controls. Obstructive CAD was associated with an increased risk of MACE, whereas anatomical AOCA features and ischemia were not.
Conclusion: In adults, the prognostic impact of AOCAs appears primarily driven by concomitant obstructive CAD rather than the anomaly itself. Given the low prevalence and event rate, multicenter collaborations are needed to refine risk stratification and management.