Background <p>Penetrating Coronary artery ulcers (PCAU) are rarely reported disruption of vascular wall integrity believed to arise from plaque rupture. Its clinical presentation often mimics other acute coronary syndromes, making timely recognition challenging. Despite their potential association with adverse cardiovascular events, they are poorly understood and no consensus guideline for their management exists.</p> Case Summary <p>64-year-old man with complex medical history including a prior coronary artery disease with stent implantation, who presented with recurrent chest pain. Cardiac catheterization identified a grade II penetrating ulcer of the proximal right coronary artery with no obstructive lesions, and he was subsequently managed conservatively with good outcome.</p> Discussion <p>Penetrating coronary artery ulcers are rare clinical findings with no specific treatment guidelines. Given the limited evidence base and the potential for progression to dissection, thrombosis, or myocardial ischemia, detailed reporting of PCAU presentations is essential to guide clinical practice. Further research is crucial to develop evidence-based treatment guidelines, especially with the advancements in intravascular imaging.</p> Conclusion <p>Penetrating coronary artery ulcer remains a rare but clinically important condition. Early recognition with multimodality imaging and individualized management strategies are key to preventing adverse outcomes. This report expands the existing evidence base and provides valuable reference material for clinicians facing similar scenarios.</p>