Objectives. To evaluate both angiographic and clinical outcomes in patients with acute coronary syndrome (ACS) presenting with isolated anterior ST-segment depression on 12-lead electrocardiogram (ECG). Background. Acute coronary syndrome is an umbrella term used to cover a spectrum of events caused by acute myocardial ischemia. Methods. The study included 50 consecutive patients with ACS. All patients had isolated ST depression in the anterior leads on admission ECG. Coronary angiography and cardiac biomarkers were done at baseline. According to TIMI flow grade in the culprit artery and the result of cardiac markers, patients were subdivided into 3 groups. Group I : TIMI flow grade 0/1 and positive markers, Group II: TIMI flow grade 2/3 and positive markers, Group III: TIMI flow grade 2/3 and negative markers. In- Hospital and 30 days outcome were reported. Results. Based on coronary angiography finding and results of cardiac markers, 12 patients (24%) had totally occluded culprit artery plus positive markers, 10 patients (20%) had TIMI flow II/III plus subtotal occlusion in the culprit artery and positive markers. While 28 patients (56%) patients had TIMI flow II/III and negative markers. In hospital and 30 days outcomes did not differ between groups. Conclusion. Among patients with ACS presenting with isolated anterior ST segment depression, about one quarter had an occluded culprit artery and elevated cardiac markers.