Premature coronary artery disease presenting as chronic total occlusion and left ventricular apical aneurysm in a 25-year-old female smoker: a case report

Premature coronary artery disease (pCAD) in young adults is well recognized. However, proximal LAD chronic total occlusion accompanied by chronic transmural infarction and left ventricular apical aneurysm is uncommon in the third decade of life and may be overlooked when symptoms are absent or mild. A 25-year-old female smoker presented with exertional chest discomfort and was subsequently diagnosed with pCAD with chronic total occlusion (CTO) of the proximal LAD and left ventricular apical aneurysm. Smoking was the predominant identifiable modifiable risk factor in the context of overweight and a borderline cardiometabolic profile, while other inherited and acquired contributors could not be fully excluded. Multimodality imaging demonstrated a chronic, predominantly transmural LAD-territory infarction with nonviable myocardium in the infarcted territory. Medical therapy and secondary-prevention strategies were initiated, while LAD CTO revascularization was deferred because extensive transmural scar and nonviable myocardium in the infarcted territory indicated limited expected functional recovery. At short-term follow-up, she remained clinically stable, reported adherence to therapy and smoking abstinence, and had no recurrent precordial discomfort; scheduled objective reassessment was pending. This case highlights the importance of maintaining a high index of suspicion and a low threshold for targeted cardiovascular evaluation in young adults with cardiovascular risk factors, particularly when exertional symptoms coexist with otherwise unexplained ECG abnormalities.