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

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 of the 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.