DOI: https://doi.org/10.36347/sjmcr.2025.v13i12.036

Pages: 3042-3046

Background: Premature coronary artery disease (CAD) in premenopausal women is rare and often underdiagnosed due to the assumed protective effects of estrogen. However, metabolic and endocrine disorders such as polycystic ovarian syndrome (PCOS) and early-onset type 2 diabetes mellitus (T2DM) significantly elevate cardiovascular risk through mechanisms including insulin resistance, dyslipidemia, endothelial dysfunction, and chronic inflammation. Despite this, PCOS is often overlooked in cardiovascular risk stratification and clinical decision-making. Case Presentation: A 36-year-old Malay woman with a history of poorly controlled T2DM (HbA1c 8.5%), PCOS, hypertension, and dyslipidemia presented with a one-month history of exertional chest discomfort and two episodes of severe angina. Her ECG showed T-wave inversion in lead III, and serial high-sensitivity troponin I levels were negative. Laboratory evaluation revealed hyperglycemia and an atherogenic lipid profile. Echocardiography showed preserved left ventricular systolic function (EF 60%) without regional wall motion abnormalities. Coronary angiography revealed severe triple vessel disease: 70% proximal stenosis of the left anterior descending (LAD) artery, two tandem high-grade lesions in the dominant left circumflex (LCx) artery, and a chronic total occlusion (CTO) of the small, non-dominant right coronary artery (RCA). After multidisciplinary heart team evaluation, coronary artery bypass grafting (CABG) was recommended due to anatomical complexity and her diabetic status. Discussion: This case illustrates the aggressive nature of coronary atherosclerosis in the setting of combined PCOS and T2DM, even in a relatively young woman. It also underscores the diagnostic challenges posed by non-classical presentations in females, where traditional tools such as ECG and biomarkers may be unremarkable despite significant coronary pathology. Evidence from trials such as SYNTAX and FREEDOM supports surgical revascularizati