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Updated: Jul 30 2022

Coronary Artery Anatomy

  • Snapshot
    • A 70-year-old man presents to the emergency room with chest pain for the past hour. He has a medical history of coronary artery disease, hyperlipidemia, and type 2 diabetes mellitus. He has a 30-pack-year smoking history and drinks alcohol regularly. His electrocardiogram reveals ST-segment elevations in leads V3 and V4. Aspirin is given and he is rushed for an angioplasty. (Myocardial infarction with left main coronary artery involvement)
  • Anatomy
    • Coronary arteries include
      • right coronary artery (RCA)
        • arises from right aortic sinus
        • supplies right ventricle and His bundle
        • branches
          • sinoatrial nodal artery
            • supplies the sino-atrial (SA) node
          • right marginal artery
            • supplies the right ventricle
        • posterior descending artery (PDA) supplies
          • AV node (supplied by atrioventricular nodal artery)
          • posterior portion of interventricular septum and ventricles
          • posteromedial papillary muscle
      • left main coronary artery (LCA)
        • arises from left aortic sinus
        • branches
          • left circumflex coronary artery (LCX) supplies
            • lateral and posterior wall of left ventricle
            • anterolateral papillary muscle
            • supplies some blood flow to SA node and AV node
          • left anterior descending artery (LAD) supplies
            • anterior portion of the interventricular septum
            • left ventricular sinus
            • anterolateral papillary muscle
            • anterior surface of the left ventricle
            • most common artery to be involved in myocardial infarction
    • Coronary arterial system dominance
      • defined by which artery supplies the PDA
      • right dominance
        • 85% of cases
        • RCA gives rise to PDA
      • left dominance
        • 8% of cases
        • LCX gives rise to PDA
      • codominance
        • 7% of cases
        • both LCX and RCA give rise to PDA
    • Coronary sinus
      • the endpoint of coronary flow and is continuous with the right atrium
      • in chronic pulmonary hypertension, coronary sinus becomes dilated
      • blood in the coronary sinus has the lowest oxygen content in the body
        • oxygen saturation levels 30%
    • Left atrium
      • most posterior part of the heart
      • enlargement can compress
        • the esophagus, causing dysphagia
        • the left recurrent laryngeal nerve, causing hoarseness
      • Localization of Myocardial Infarctions (MI)
      • Leads with ST-Segment Elevation
      • Location of MI
      • Vessel(s) Affected
      • V1-V2
      • Septal
      • LAD
      • V3-V4
      • Anterior
      • LAD
      • V5-V6
      • Apical
      • LAD, LCX, or RCA
      • I and aVL
      • Lateral
      • LCX
      • V7-V9
      • Posterior
      • RCA and LCX
      • II, III, and aVF
      • Inferior
      • RCA and LCX
  • Pathology
    • Coronary steal phenomenon
      • myocardial ischemia
        • narrowed coronary arteries are dilated maximally to increase blood flow to ischemic tissues
          • when a vasodilator is used, coronary arteries that are not narrowed vasodilate
            • narrowed coronary arteries cannot further dilate
            • thus, blood flow is stolen from the narrowed arteries
          • classically, dipyridamole is associated with this
            • also used for cardiac stress testing
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