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Coronary artery anomalies are traditionally classified into anomalies of origin, course and termination. One of the anomalies of origin is absence of the left main coronary artery ( LMCA), where the left anterior descending ( LAD), the circumflex ( Cx) and the ramus medianus ( RM) (when present) arteries originate directly from the left aortic sinus. The study aimed to document the prevalence of absent LMCA, discuss its possible embryogenesis and clinical relevance. A review of 407 coronary angiograms performed by cardiologists of three private hospitals in the eThekwini Municipality area of KwaZulu-Natal, South Africa, was performed. The LMCA was absent in 9.6% (39/407) of the coronary angiograms. The LAD and Cx arteries originated directly from the left aortic sinus with a single ostium in 8.6% (35/407) and separate ostia in 1% (4/407) of the angiograms. In four of the angiograms with absent LMCA, a RM artery was recorded originating directly from the left aortic sinus in addition to the LAD and the Cx arteries. Angiographic detection of the anomalies of the coronary arteries is essential in the determination of the significance of such findings and their management. [ABSTRACT FROM AUTHOR]