A myocardial bridge is a coronary anomaly or rather a variant of intrinsic coronary arterial anatomy where a tunneled length of an epicardial artery dives through the myocardium. Most myocardial bridges have been considered 'benign' and not associated with symptoms especially if short and superficial (<2 mm). However, in this case, we have a very deep (~5 mm) and long (>25 mm) tunneling of a strong ramus intermedius artery which could indeed explain this patient's symptoms due to systolic compression and subsequent early diastolic delay also known as milking effect.

There are no clear guideline recommendations with regard to the management of this entity ¹. As proposed in a recent state-of-the-art review ¹ we recommended close clinical follow-up and medical therapy with beta-blockers or calcium channel blockers as worthy consideration in addition to risk factor modification and preventive therapy, which she should get for her non-obstructive coronary artery disease anyway ², as well as further stress testing preferably with a dobutamine stress test ³ in the setting of persisting symptoms.

Courtesy: Dr Waltraud Ibe