Abstract
Aortocaval fistulas (ACFs) are rare with varied etiologies. Symptoms can be acute or delayed with predominant manifestations being high output cardiac failure. Acute coronary syndrome due to ACF has not been widely reported. We present a case of a 68-year-old male who presented with signs and symptoms suggestive of acute coronary syndrome. This was confirmed by electrocardiogram changes and a rise in cardiac enzymes. A large abdominal aortic aneurysm was diagnosed initially by imaging without evidence of leak or rupture. A coronary angiogram showed only mild diffuse disease. On further reviewing, the computerized tomography imaging revealed an ACF. This was subsequently repaired with rapid improvement in his condition. Acute coronary syndrome is an unusual presentation of ACF with inadequately understood pathophysiological mechanisms. Prompt diagnosis and surgical management of this fistula are paramount to reduce mortality and morbidity.