As clinicians, we treat symptomatic patients with coronary artery disease manifesting as either angina, anginal-like discomfort, or exertional dyspnoea. In some of these patients, symptoms progress rapidly either to rest pain and unstable angina or myocardial infarction, or to sudden death from malignant arrhythmias. However, not all patients who present with these acute coronary syndromes necessarily have a history of symptoms. In fact, in some studies the majority of such patients was asymptomatic before the acute syndrome. The acute progression of a “silent” atherosclerotic plaque to complete or nearly complete occlusion is a common substrate for an acute presentation of coronary artery disease in patients with and without prior symptoms. This editorial discusses the fact that progression to the acute presentation of coronary disease is not proportionately related to the prior severity of the coronary stenosis.