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A 64 year old woman presented with chest pain. Exercise stress testing showed upsloping ST segment depression (maximally 0.15 mV in precordial leads) without symptoms. Coronary angiography showed an isolated single coronary artery with the left main arising from the proximal part of the normal right coronary artery and crossing the base of the heart anterior to the great vessels to its inherent normal position (left, 30° right anterior oblique projection; right, 60° left anterior oblique projection).
Isolated single coronary artery is a very rare congenital anomaly. It occurs in approximately 0.07% of the population undergoing coronary angiography. However, in the absence of atherosclerosis the pathological importance remains speculative, despite chest discomfort combined with suspicious exercise stress testing.