We present a case of 62 year old male presenting with effort dyspnea NYHA class II with evidence of inferior ischaemia in EKG. Being a nonharbor of conventional coronary risk factors and as the patient was unable to perform TMT in view of disabling osteoarthritis, we subjected the patient to conventional invasive coronary angiogram which revealed an empty right coronary sinus with anomalous origin from right coronary artery (RCA) from left coronary sinus with interarterial course (between aorta and pulmonary artery) delineated in 256 slice CT coronary angiogram. Being notorious to develop syncope, artherothrombosis, torsades de pointes and sudden cardiac death in its natural course, this anomaly presented with a more benign way in present case. A vigilant look should be there to left sinus when someone encounters an empty right sinus during routine coronary angiography and CT coronary angiogram must be taken to delineate its anatomic route that dictates its natural history.

Keywords: Coronary; Syncope; Interarterial.