coronary artery anomalies of origin and course are relatively common incidental findings at angiography , but they are symptomatic only in a few cases . furthermore , coronary bridging can be considered common and it rarely has a significant clinical impact . in clinical practice , different conditions may give rise to a positive electrocardiogram ( ecg ) stress test . here , we describe a case of a coronary artery anomaly of origin and course associated with a myocardial bridging , involving two different coronary arteries , in which the first step to achieve the correct diagnosis was a positive ecg stress test . an 82-year - old former professional soccer player was referred to our department for diagnosis of heterozygous familial hypercholesterolemia . his family history was noteworthy because of his father 's sudden cardiac death at the age of 35 years . the patient was in good health and did not report any history of syncope or exercise - induced symptoms during his career . due to the diagnosis of familial hypercholesterolemia , he underwent a screening ecg stress test that showed a 2 mm horizontal st depression on leads v4 to v6 [ figure 1a ] , though he showed no symptoms . 82-year - old man with positive ecg test but no symptoms diagnosed with an association of a malignant coronary artery anomaly of origin and course and a long myocardial bridging over the obtuse marginal branch . a ) 12-lead electrocardiogram stress - test shows the 2 mm horizontal st depression on leads v4 to v6 , in absence of symptoms , during exercise . b ) multislice computed tomography ( msct ) with 3d volume rendering reconstruction reveals the abnormal origin of the left anterior descending ( lad ) artery from the right sinus of valsalva ( arrow ) . c ) msct maximum intensity projection ( mip ) reconstruction demonstrates the anomalous course of lad artery ( arrowheads ) running between the aorta and the right ventricular outflow tract ( malignant variant ) . d ) msct mip reconstruction illustrates the intramural course (  myocardial bridging  ) of the obtuse marginal branch ( arrowheads ) within the left ventricular lateral wall . ao : ascending aorta , rvot : right ventricular outflow tract , lv : left ventricle , rsv : right sinus of valsalva , la : left atrium , ra : right atrium , lsv : left sinus of valsalva , lv : left ventricle . in order to exclude coronary artery disease , the patient underwent a 128-slice coronary - computed tomography ( multi - slice ct [ msct ] ) scan that revealed abnormal origin of the left anterior descending ( lad ) artery from the right sinus of valsalva ( rsv ) with malignant course of the artery running between the aorta and the right ventricular outflow tract [ figure 1b and c ] . moreover , a long muscular bridge over the obtuse marginal branch originating from the circumflex artery was also demonstrated [ figure 1d ] . based on the localization of the horizontal st segment depression on leads v4-v6 , the result of the ecg stress test could be probably attributed to the presence of the myocardial bridging of the obtuse marginal branch within the left ventricular lateral wall , rather than to the lad malignant anomaly . since the patient was asymptomatic , only lipid lowering therapy consisting of simvastatin plus ezetimibe was given . the patient is still completely asymptomatic for ischemic heart disease and his low - density lipoprotein and non - high - density lipoprotein cholesterol levels are within the range recommended by atp iii guidelines for patients with familial hypercholesterolemia . coronary artery anomalies can be considered not uncommon , having incidence of 0.6 - 1.3% among angiographic series and 0.3% in autopsy series . however , lad arising from the rsv is a rare anomaly with an incidence of 0.017 - 0.03% . due to its course between two big vascular structures ( the aorta and the pulmonary artery trunk or the right ventricular outflow tract ) , it is considered a malignant variant and known to be associated with increased risk of sudden death , especially in young athletes . cardiovascular symptoms ( i.e. , chest pain , exertional dyspnea , syncope , or dizziness ) occur in 18 - 30% of all cases of coronary anomalies . however , in our case , the patient was completely asymptomatic and reached the elderly age of 82 years without any cardiac - related symptoms despite his athletic career . ecg stress test is generally considered of little diagnostic value , but coronary angiography and msct are valuable tools in achieving a diagnosis . as coronary anomalies , myocardial bridges are congenital in origin and it has been estimated that an average of 30 - 50% of adults have myocardial bridges . most of the myocardial bridges do not produce symptoms and the diagnosis is usually an incidental finding , as in our case . however , muscular bridges over the circumflex artery are a rare anomaly , as the bridging in most cases is located over the lad . in the absence of symptoms , no therapy for myocardial bridges is recommended . in our elderly patient , the concomitant association between a malignant coronary artery anomaly and a muscular bridge , a finding rarely described before , raises the hypothesis that coronary artery anomalies and myocardial bridges may share a similar developmental pattern , as is suggested for the association between muscular bridging and coronary arterial dominance . ecg stress test , usually considered of little value for detection of coronary anomalies , was in our case the first diagnostic clue leading to the final diagnosis .
malignant coronary artery anomalies and myocardial bridging are more common findings in young patients with cardiac symptoms , but these two associated yet different types of anomalies in an elderly patient has been rarely described . 
 the following case describes the diagnostic use of 128-slice coronary - computed tomography images of an 82-year - old male , former professional soccer player , who reached the age of 82 years without any symptoms of coronary heart disease . in this patient , 
 an association of a malignant coronary artery anomaly of origin and course ( left descending coronary artery originating from the right sinus of valsalva running between the aorta and the right ventricular outflow tract ) , together with a long myocardial bridging over the obtuse marginal branch was diagnosed by multi - slice computed tomography thanks to an initial positive electrocardiogram screening stress test .