The Missing Pulse behind a Failing Heart: Coronary Takayasu Arteritis in an Adolescent

Abstract

Background: Takayasu arteritis (TA) is a chronic granulomatous large-vessel vasculitis that predominantly affects young women. Although vascular stenosis involving the aorta and its branches is characteristic, cardiac manifestations are heterogeneous and include coronary artery disease, heart failure, renovascular hypertension, and valvular dysfunction. Cardiovascular complications are the principal determinants of long-term morbidity and mortality. Coronary artery involvement is uncommon, occurring in approximately 7–15% of patients and usually involving the coronary ostia or proximal segments. Due to early nonspecific constitutional symptoms, delayed diagnosis remains common despite advances in imaging and immunomodulatory therapy. Case Summary: We report a 17-year-old girl who presented with rest angina and had been receiving treatment for presumed non-ischaemic dilated cardiomyopathy with severe left ventricular systolic dysfunction (LVEF 20%) before subsequently developing non-ST-elevation acute coronary syndrome. Coronary angiography demonstrated chronic total occlusion of the left anterior descending artery with well-developed right coronary collateralisation. Percutaneous coronary intervention was successfully performed. CT aortography revealed complete right subclavian artery occlusion and diffuse left subclavian narrowing, establishing the diagnosis of Takayasu arteritis with coronary involvement. Conclusion: Coronary involvement in Takayasu arteritis is uncommon and may be overlooked in young patients presenting with heart failure. Coronary Takayasu arteritis can present initially as severe ventricular dysfunction and recurrent heart failure before overt acute coronary syndrome. The combination of pulse deficits, limb claudication and unexplained cardiomyopathy should prompt evaluation for large-vessel vasculitis. Early recognition through careful vascular examination and multimodality imaging may permit myocardial salvage and improve outcomes.