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BACKGROUND An anomalous origin of a coronary artery from the opposite sinus of Valsalva (ACAOS) is a rare congenital coronary abnormality that is usually asymptomatic throughout life. However, an anomalous coronary artery arising from an atypical aortic location can lead to myocardial ischemia, exertional symptoms, or even sudden cardiac death. Therefore, early recognition and risk stratification are essential. Clinical management of ACAOS should be highly individualized and guided by detailed anatomical features, clinical symptoms, and evidence of ischemia. This report describes an older woman who presented with new-onset chest pain as the first clinical manifestation of previously undiagnosed ACAOS. CASE REPORT A 70-year-old woman presented with 5 days of progressive chest tightness and 20 days of recurrent dizziness associated with poorly controlled hypertension. Initial conventional medical therapy provided inadequate symptom relief. Subsequent coronary angiography revealed an anomalous left circumflex artery originating independently from the right sinus of Valsalva, with 3 separate coronary ostia and concurrent clinically significant atherosclerotic stenosis. She underwent uncomplicated percutaneous coronary intervention of the right coronary artery, achieving successful revascularization and complete resolution of her presenting symptoms. CONCLUSIONS This report describes a rare case of ACAOS presenting with de novo chest pain in an older woman, highlighting the critical importance of accurate anatomical characterization and tailored, individualized management for optimal clinical outcomes.