Introduction: Takayasu arteritis (TA) is a chronic granulomatous vasculitis affecting large vessels such as the aorta and its branches. Coronary involvement is a serious complication causing acute coronary syndromes (ACS). Pharmacological treatment aims to suppress inflammation and prevent progression. Corticosteroids induce remission, while immunosuppressants like cyclophosphamide maintain control in severe cases.
Case: A 61-year-old woman with TA involving multiple arteries—including both subclavians, left iliac, inferior mesenteric, right renal, and right iliac—was admitted for non-ST elevation ACS (NSTEMI). Echocardiography showed moderately reduced left ventricular ejection fraction due to basal inferior and inferolateral scarring. Coronary CT angiography revealed chronic occlusion of the proximal-mid right coronary artery and inflammatory changes in circumflex and obtuse marginal arteries, consistent with active vasculitis. Due to difficult arterial access, invasive angiography was deferred. She initially received dual antiplatelet therapy and anticoagulation.
After multidisciplinary consultation, high-dose intravenous methylprednisolone pulses (250 mg) followed by oral prednisone (40 mg daily) were given. Cyclophosphamide was added as a steroid-sparing immunosuppressant to maintain inflammation control. This approach led to clinical improvement and chest pain resolution, with stable imaging at three months. The patient had no further vascular events related to TA but died from bilateral COVID-19 pneumonia, likely worsened by immunosuppression.
Discussion: Corticosteroids rapidly reduce vascular inflammation by inhibiting cytokine production and leukocyte activity, key for inducing remission. Cyclophosphamide, an alkylating agent, provides potent immunosuppression by inhibiting immune cell proliferation, essential for controlling severe vasculitis affecting critical vessels. This combined therapy effectively controlled coronary inflammation, avoiding risky revascularisation.
Conclusion: Immunosuppressive therapy with corticosteroids and cyclophosphamide can manage coronary involvement in TA, controlling inflammation and stabilising ischaemic symptoms without invasive procedures. This case highlights the need to balance vasculitis control and infection risk, emphasising multidisciplinary care and close monitoring in complex TA cases.