Coronary artery aneurysms are uncommon but potentially hazardous entities found on a small percentage of coronary angiograms. The best management strategy remains to be determined; the coexistence of obstructive coronary artery disease is the main determinant of prognosis. We report the case of a middle-aged woman with mixed aneurysmal and obstructive coronary artery disease presenting as an acute myocardial infarction, probably due to atherosclerosis. The unusual severity and complexity of the angiographic presentation of this case, with involvement of all major coronary arteries, raises important issues in terms of the patient's treatment options.