Tako-Tsubo cardiomyopathy (TTC) predominantly affects elderly people with a high prevalence of cardiovascular risk factors. Therefore, one would expect to encounter incidental coronary artery disease in a significant number of cases. In fact, the prevalence of mild coronary artery disease (CAD), by angiography, has been reported to be in the range of 30%–60%. Similarly, more severe stenotic lesions in at least one coronary vessel were incidentally found in 10%–35% of patients with the disease. Using intravascular ultrasound in a series of 10 patients with TTC, coronary atherosclerosis was demonstrable in all patients, although five patients had normal coronary angiograms. Therefore, TTC and CAD are not mutually exclusive disease entities. The incidental finding of coronary lesions, even if significant, should not automatically lead to a dismissal of the diagnosis of TTC. Rather, a case-by-case approach using additional imaging modalities should be endorsed.