AIM To define the role of cardiac magnetic resonance(CMR) by analyzing a particular group of patients with suspected acute coronary syndrome(ACS) and normal coronary angiogram. METHODS From January 2009 to December 2015, we examined 220 patients with clinical suspicion of ACS, Troponin elevation [the threshold used to define a positive Troponin T test(TnT) was 0.1 ng/mL ] and no significant coronary disease at angiography(the patients were considered to have significant angiographic disease only a 50% stenosis was detected in any of their coronary arteries). The role of CMR with the late gadolinium enhancement was evaluated.RESULTS CMR was performed to 190 patients(86%) of this group which reveals: Myocarditis in 90 patients(47%); apical ballooning(Tako-Tsubo syndrome) in 32 patients(17%); myocardial infarction(MI) in 40 patients(21%) and no clear diagnosis identified by CMR in 28 patients(15%). A comparison with previous studies was also made. Clinical and echocardiographic follow-ups were performed at 12 ± 2 mo and no major adverse cardiac events were revealed.CONCLUSION There is a group of patients with clinical suspicion of ACS displaying normal coronary angiograms. CMR was demonstrated to be a valuable tool in the differential diagnosis evaluation of myocarditis, apical ballooning and MI. AIM To define the role of cardiac magnetic resonance (CMR) by analyzing a particular group of patients with suspected acute coronary syndrome (ACS) and normal coronary angiogram. METHODS From January 2009 to December 2015, we examined 220 patients with clinical suspicion of ACS, Troponin elevation [the threshold used to define a positive Troponin T test (TnT) was 0.1 ng / mL] and no significant coronary disease at angiography (the patients were considered to have significant angiographic disease a 50% stenosis was detected in any of their coronary arteries). The role of CMR with the late gadolinium enhancement was done .RESULTS CMR was performed to 190 patients (86%) of this group which reveals: Myocarditis in 90 patients (47%); apical ballooning (Tako-Tsubo syndrome) in 32 patients (17%); myocardial infarction (MI) in 40 patients (21%) and no clear diagnosis identified by CMR in 28 patients (15%). A comparison with previous studies was also made. Clinical and echocardiographic follow-ups were performed at 12 ± 2 mo and no major adverse cardiac events were revealed. CONCLUSION There is a group of patients with clinical suspicion of ACS displaying normal coronary angiograms. CMR was demonstrated to be valuable tool in the differential diagnosis evaluation of myocarditis, apical ballooning and MI.