Unusual coronary artery disease presentation: take the time to bury the hatchet and the stent, a case report.

Background: Coronary artery disease (CAD) secondary to coronary arteritis (CA) is a rare and challenging condition to diagnose, often resulting in poor clinical outcomes. Conventional coronary angiography lacks the sensitivity to identify inflammatory causes, leading to underdiagnosis and inappropriate treatment. Advanced imaging techniques, particularly cardiac computed tomography angiography (CCTA), appear to be invaluable tools to correctly identifying CA as the underlying cause of atypical CAD. Case summary: We describe the case of a 74 year old patient without traditional risk factor who presented with chest pain, a positive clinical and electrical stress test. Given the highly atypical form of CAD on CCTA characterized by a diffuse, circumferential thickening of coronary arteries, an inflammatory cause was suspected. Large vessel vasculitis was confirmed by fluorodeoxyglucose-positron emission tomography scan (FDG-PET). Treatment with aspirin, statins, beta-blockers, and corticosteroids resulted in symptom resolution, with subsequent imaging showing regression of both vessels hypermetabolism and coronary arterial thickening, thus avoiding the need for coronary revascularization. Discussion: This case highlights the importance of multimodal imaging, particularly CCTA and FDG-PET, in diagnosing CA in patients with atypical CAD presentations. Early recognition and management of active inflammation can prevent unnecessary revascularization and improve clinical outcomes.