Abstract Anomalous coronary arteries (ACA) represent a congenital disorder with an anomalous location of the coronary ostium and/or vascular course. Although most individuals with ACA are asymptomatic and remain undiagnosed, some ACA variants are clinically significant leading to symptoms and even adverse cardiac events. Currently, disease prevalence, pathophysiological mechanisms, risks of sudden cardiac death, and the optimal assessment and treatment strategies among subtypes of ACA remain largely unknown. Consequently, there is a lack of guidelines regarding imaging, sport restriction, and treatment options in individuals with ACA at all ages. Cardiac imaging techniques may play a pivotal role in the assessment of individuals with ACA and may offer guidance toward an optimal treatment strategy. This state-of-the-art review highlights current challenges and future perspectives with a special focus on the role of noninvasive multimodality imaging in patients with ACA.