Acute intra-coronary thrombus on cardiac CT imaging

A 48 year old male known to have controlled essential hypertension, untreated dyslipidemia, and a heavy smoker presented with retrosternal atypical chest pain intermittent in nature. his serial troponins were negative and resting 2d echocardiography study did not show any segmental wall motion abnormality; exercise stress test reproduced his chest pain at 6 mets with 2 mm st depression in the inferolateral leads. coronary ct study showed calcification in the mid and distal parts of the left anterior descending artery (lad) (fig. 1) with mixed plaque type causing approximately 40% stenosis with impressive vessel remodeling in that area; also it revealed a filling defect within the coronary artery lumen with contrast around that defect and an absence of calcium within the defect. in addition the defect had classically low attenuation (50 hounsfield units) which makes it very likely an acute thrombus of lad (fig. 2 and zoomed view in fig. 3) indicating most likely acute plaque with thrombus formation; the rest of the coronary tree did not show any other significant pa thology(fig. 4). the patient refused hospital admission and was treated with dual anti-platelet therapy and low molecular weight heparin (lmwh) and his symptoms resolved.