Working Diagnosis:
Symptomatic Myocardial Bridging of the Left Anterior Descending Artery

Treatment:
Medical management attempted with calcium channel blockers. Patient did not tolerate well secondary to side effects. Patient was then put on a max tolerated dose of beta blockers. This was a low dose given patients' low resting heart rate. Patient continued to have anginal symptoms with minimal exertion. This resulted in multiple ED visits and hospitalizations. Patient underwent a successful surgical unroofing of his LAD by a specialized cardiothoracic surgeon.

Outcome:
Patient is currently in cardiac rehab and doing well post-operatively. If the patient is able to return to symptom free exercise with normal stress testing, he would like to return as an active duty service member.

Author's Comments:
Myocardial bridging (MB) is a rare cause of exertional chest pain and syncope. The prevalence of MB is estimated to be 25%; however, the vast majority of these patients are asymptomatic. It is a congenital condition with a potential genetic component to it. Symptomatic patients typically present with anginal symptoms. Diagnosis is best made with coronary angiography. Conservative management includes beta blockers while surgical management includes stent placement, coronary bypass, or myocardial unroofing. The best practice surgical management is myocardial unroofing. The newest sports cardiology 2025 American Heart Association and American College of Cardiology comment on coronary anomalies and myocardial bridging. For asymptomatic athletes with incidental MB they should not be restricted from sport. Symptomatic athletes require a shared decision making model. If they are medically managed, they need resolution of symptoms and normal provocative testing. For patients who undergo surgical repair, they will need complete sternal healing, have no complex ventricular arrhythmias, complete resolution of symptoms, and normal provocative testing.

Editor's Comments:
Myocardial bridging of the left anterior descending artery is characterized by a segment of the coronary artery that tunnels through the myocardium, leading to systolic compression and potential ischemia. Myocardial bridging is present in up to 30% of autopsy studies but far less often diagnosed clinically usually due to lack of symptoms. Symptoms are more likely when the bridge is deep (>3 mm) or long (>25 mm). The American College of Cardiology and American Heart Association recommend beta-adrenergic blocking agents as first-line therapy in symptomatic patients, as these agents reduce heart rate and myocardial contractility, thereby decreasing the degree of systolic compression and improving symptoms. For patients with persistent symptoms despite optimal medical therapy, the societies advise restriction to low-intensity sports to minimize the risk of exercise-induced ischemia and sudden cardiac death. Surgical correction may be considered if symptoms are refractory to medical management, although the long-term risks and benefits remain uncertain due to limited data. it is important to recognize that most myocardial bridging is clinically silent, but severe cases can lead to significant morbidity. Provocative testing may be useful in confirming ischemia in ambiguous cases. Management should be individualized, with a focus on symptom control and risk mitigation, as outlined by the American College of Cardiology and American Heart Association.

References:
1. Kim JH, Baggish AL, Levine BD, et al. Clinical Considerations for Competitive Sports Participation for Athletes With Cardiovascular Abnormalities: A Scientific Statement From the American Heart Association and American College of Cardiology. Circulation. 2025;151(11):e716-e761. doi:10.1161/CIR.0000000000001297

2. Thompson PD, Myerburg RJ, Levine BD, Udelson JE, Kovacs RJ. Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Task Force 8: Coronary Artery Disease: A Scientific Statement from the American Heart Association and American College of Cardiology. J Am Coll Cardiol. 2015;66(21):2406-2411. doi:10.1016/j.jacc.2015.09.040

3. Thompson PD, Myerburg RJ, Levine BD, Udelson JE, Kovacs RJ. Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Task Force 8: Coronary Artery Disease: A Scientific Statement from the American Heart Association and American College of Cardiology. J Am Coll Cardiol. 2015;66(21):2406-2411. doi:10.1016/j.jacc.2015.09.040

4. Matta A, Nader V, Canitrot R, et al. Myocardial bridging is significantly associated to myocardial infarction with non-obstructive coronary arteries. Eur Heart J Acute Cardiovasc Care. 2022;11(6):501-507. doi:10.1093/ehjacc/zuac047

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