The incidence of coronary artery aneurysms (CAA) in the general population ranges from 0.3% to 5.3%. Although CAA may cause thrombus formation or undergo progressive expansion with subsequent rupture, their natural history remains largely unknown. Appropriate treatment, including percutaneous, surgical or conservative management, may be challenging, particularly in acute settings. We describe the acute management of two patients with ST-elevation myocardial infarction where CAA was identified as the culprit lesion.