Atypical Presentation of Chronic Left Anterior Descending Occlusion - Heart Failure Without Angina as the Initial Manifestation

Sep 30, 2026

Uploaded by acoobca

Case report presents a middle-aged patient with few conventional cardiovascular risk factors in whom chronic left anterior descending (LAD) artery occlusion first manifested as severe heart failure with pulmonary edema rather than angina. Progressive dyspnea at rest and lower-limb edema developed over about two weeks. Echocardiography showed markedly reduced left ventricular ejection fraction (~18%) with pleural fluid and pulmonary congestion, while troponin and CK-MB did not indicate acute infarction. Coronary angiography identified proximal LAD chronic total occlusion (CTO) with classic features and collateral filling from the dominant right coronary artery.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages7

Reading Time18 min

AccessFree to download

Abstract

Introduction

Case Presentation

Review began 11/30/2025 Review ended 12/05/2025 Published 12/10/2025 © Copyright 2025 Gembala et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CCBY 4.0. , which permits unrestricted use , distribution , and reproduction in any medium , provided the original author and source are credited. DOI: 10.7759/cureus.98903 Open Access Case Report Atypical Presentation of Chronic Left Anterior Descending Occlusion: Heart Failure Without Angina as the Initial Manifestation Wiktoria M. Gembala 1, Julia K. Marczuk 1, Iwona Kobielusz-Gembala 2 1. Faculty of Medicine, Jagiellonian University Medical College, Krakow, POL 2. Cardiology Department, Medicome Clinic Oswiecim, Oswiecim, POL Corresponding author: Wiktoria M. Gembala, [wiktoria.gembala@wp.pl](wiktoria.gembala@wp.pl) Abstract We present the case of a middle-aged patient with few conventional cardiovascular risk factors (no hypertension, diabetes, or smoking), whose first manifestation of chronic left anterior descending (LAD) artery occlusion was severe heart failure accompanied by pulmonary edema. The patient was admitted with progressively worsening dyspnea at rest for about two weeks and edema of the lower limbs. Echocardiography revealed a severely reduced left ventricular ejection fraction (~18%), along with fluid in both pleural cavities and signs of pulmonary congestion. Cardiac markers (troponin, CK-MB) did not confirm an acute infarction. After clinical stabilization, coronary angiography was performed, revealing a proximal LAD chronic total occlusion (CTO) with classic angiographic features, including a blunt proximal stump, absent antegrade flow, and well-developed collateral filling of the distal LAD from the dominant right coronary artery. The patient was scheduled for elective revascularization ofthe LAD CTO, which had not yet been performed. The reversed order of symptoms (heart failure without angina or acute infarction) and the relative paucity of traditional risk factors in this middle-aged patient represent an unusual clinical presentation. This case highlights the importance of considering an ischemic etiology of heart failure even when symptoms are atypical or non-anginal. Categories: Cardiology, Internal Medicine Keywords: chronic total occlusion, collateral circulation, coronary artery disease, heart failure, young patient Introduction Chronic total occlusion (CTO) of a coronary artery is detected in 15-30% of patients undergoing angiography, especially in populations with extensive atherosclerotic changes [1] . Most CTOs involve the right coronary artery (RCA), whereas CTO of the left anterior descending (LAD) artery is less common but clinically more consequential due to the large myocardial territory it supplies. CTOs typically occur in older patients with multiple cardiovascular risk factors (e.g., hypertension, dyslipidemia, diabetes, tobacco use) [2] . Such patients typically report classic coronary symptoms, such as angina pectoris or symptoms of acute coronary syndrome [2] . Meanwhile, patients with diagnosed heart failure often exhibit symptoms of chronic coronary disease or ischemic cardiomyopathy, but it is rare for heart failure to manifest first as the initial sign of coronary disease [2] . This case report has educational value, as it presents an atypical sequence of symptoms-severe heart failure as the first manifestation of chronic LAD occlusion-in a middle-aged patient with few traditional risk factors and no prior ischemic events and without angina or evidence of acute infarction. Case Presentation The patient reported no prior history of exercise intolerance, exertional dyspnea, chest discomfort, or cardiovascular symptoms. No orthopnea or paroxysmal nocturnal dyspnea was documented. His functional capacity had been normal until approximately two weeks before admission, when rapidly progressive dyspnea and lower-limb edema developed, consistent

FAQs

What was the initial manifestation of chronic LAD occlusion in this patient?

Severe heart failure with pulmonary edema occurred as the first sign, without angina or evidence of acute infarction.

How did echocardiography and cardiac markers contribute to the diagnosis?

Echocardiography showed a severely reduced left ventricular ejection fraction (~18%) with pleural fluid and pulmonary congestion, while troponin and CK-MB were within normal limits, arguing against acute myocardial injury.

What did coronary angiography reveal?

It demonstrated a proximal LAD chronic total occlusion (CTO) with classic angiographic features, including a blunt proximal stump and absent antegrade flow, with well-developed collateral filling from the dominant right coronary artery.

Sep 30, 2026

Uploaded by acoobca