Aim To analyse postmortem cases of myocardial infarction (MI) with normal coronary arteries in terms of patient characteristics, features of the MI and risk factors.

Methods This retrospective non-case controlled study was carried out at a specialist cardiac pathology department at a tertiary cardiac referral centre. Cases of histologically confirmed MI and normal coronary arteries during the period 1996–2010 were identified and analysed for the presence of risk factors.

Results Nineteen cases of histologically confirmed MI and normal coronary arteries were identified with a similar gender ratio 1:1.1 (male:female) and mean age of 33±12 years (range 14–58). All patients died suddenly. The location of the infarct was variable, with left anterior descending artery territory being the single most prevalent (47%). Risk factors were identified in the majority of cases (n=14), with some cases experiencing more than one association, including alcohol and/or predominately class A drug use (n=7), including cocaine, inflammation (n=2), hypercoagulable state (n=3) and exertion (n=2).

Conclusions Current data regarding prognosis in MI with normal coronary arteries suggests a favourable outcome in the context of major cardiovascular events. No large series of fatal cases have been reported. This study highlights that this entity can be fatal and its prognosis may be less favourable than currently considered. This autopsy series also demonstrates that the causation of MI with normal coronary arteries is complex and multifactorial, including a history of alcohol and/or drug use. It also highlights the importance of accurate epidemiological data from referring pathologists.