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Background: Coronary angiographies performed during acute coronary syndrome show different coronary morphologies-vessel occlusions, thrombi and various types of stenoses. In a few cases of acute coronary syndrome, angiography reveals normal coronary arteries. It is the purpose of this study to analyze this specific subset of patients who presented with an acute coronary syndrome but had a normal coronary angiogram with respect to the preangiographic diagnostics, risk stratification and clinical follow-up. Methods and results: A total of 897 coronary angiographies were performed as an emergency procedure in our institution. The majority of patients(n=821) presented with coronary artery disease and the majority was treated by mechanical revascularization(86.3%). In 76 patients(8.5%), no coronary artery stenosis was documented. However, according to the preangiographic risk stratification, coronary artery disease was expected in these patients. Observations documented angiographically included coronary spasms(6.6%) and muscle bridges(5.3%). During a mean follow-up of 11.2±6.4 months, one patient developed an acute myocardial infarction requiring coronary intervention. All other patients were free of any cardiac event. Conclusions: In summary, we have to consider that coronary angiography may not always detect the cause of myocardial ischemia in every patient. There is a small group of patients with normal coronary angiograms during acute coronary syndrome. Additional diagnostic procedures like intravascular ultrasound(IVUS) or the assessment of intracoronary physiological parameters may increase the diagnostic value of angiography.