The authors present the case of a 47-year-old man, with hypertension and dyslipidemia as cardiovascular risk factors, who had come to the emergency department in 2008 for chest pain. Diagnostic exams at that time (ECG and cardiac biomarkers) revealed no signs of acute ischemia, but exercise testing was positive for myocardial ischemia. Invasive coronary angiography was performed, which showed no angiographically significant coronary lesions. He subsequently underwent myocardial perfusion scintigraphy, which revealed no evidence of ischemia.

Due to persistence of symptoms, in 2012 exercise testing was repeated, which was positive for ischemia. In order to clarify the clinical picture, he was referred to our hospital for cardiac computed tomography (CT) angiography. This showed a zero calcium score (Figure 1), corresponding to the 25th percentile for age and gender, and revealed 50–70% stenosis with a non-calcified eccentric plaque in the distal left main/proximal anterior descending artery (Figure 2).

Figure 1.

Calcium score.

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Figure 2.

Computed tomography angiography showing significant plaque in the distal left main artery.

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Invasive coronary angiography confirmed significant coronary artery disease (Figure 3) and the patient was referred for coronary artery bypass grafting. The authors did not have access to the initial coronary angiography since this was performed in a different institution, and at referral the patient was in possession of clinical information only, together with the request for cardiac CT angiography.

Figure 3.

Invasive coronary angiography showing significant plaque in the left main artery.

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This case highlights the important contribution that cardiac CT angiography can make to the diagnosis and characterization of coronary artery disease.