Although congenital heart diseases are uncommon in the elderly, coronary artery anomalies may be incidentally discovered in old age. We sought to determine the incidence and clinical features of coronary artery anomalies (CAAs) in patients over 65 years of age. Patients and methods Medical records of patients undergoing coronary artery angiography in the years 1997-2002 at the Legnago General Hospital were retrospectively reviewed. The clinical profiles of all patients with CAAs and CAA subtypes were noted. Comparison between patients under and over 65 was performed. Data are given as mean standard deviation and as percentages. Results Sixty-six patients (1.21% , Female/Male 22/44, mean age 65.3 ± 10.6 years) out of the 5450 who underwent coronary angiography in the years 1997-2002 had CAAs. In most cases (63% , 41/66 patients), the patients were over 65. CAAs were discovered incidentally in these elderly patients while undergoing coronary artery angiography for dilated cardiomyopathy, ischemic heart disease, and valvular heart disease in 75% of the cases (30/41 patients). Patients over 65 had more cardiac comorbidities and a higher incidence of coronary atherosclerosis. Conclusions The angiographic incidence of CAAs in elderly patients is increasing as the population ages and this occurrence calls for a wider knowledge of the anatomy and pathophysiology of CAAs among geriatric cardiologists. Elderly patients seem to present with lower risk coronary anomalies (separated origin of left anterior descending coronary artery and circumflex artery, origin of circumflex artery from the right sinus or the right coronary artery, double coronary artery) but have a higher risk profile compared to younger patients due to the frequency of cardiac comorbidities and superimposed coronary artery atherosclerosis.