CASE PRESENTATION: A 53 year old male smoker with a history of hypertension, diabetes mellitus, bicuspid aortic valve with aortopathy s/p bentall procedure 4 months prior, triple vessel disease s/p coronary artery bypass came to the hospital for sudden onset severe left side chest pain radiating to the arm associated with diaphoresis, shortness of breath. Initial electrocardiogram (EKG) was unremarkable but patient continued to have escalating pain when a repeat EKG later revealed ST elevations in aVR, V1-V3 with diffuse ST depression in lateral and inferior leads(Fig-1). Initial troponin on admission was noted to be 0.13. Intravenous heparin bolus was given, nitroglycerin infusion initiated and patient was taken for an urgent coronary angiogram which revealed 99% left main stenosis(Fig-2). . Patient also had brief episodes of non sustained ventricular tachycardia during the procedure.Angiography revealed TIMI I flow in left coronary system. Following pre-dilatation of left main coronary, flow improved. Drug eluting stent was deployed and post-dilatation inflations performed with good angiographic result and excellent flow. EKG normalized and no further arrhythmias were noted. Patient was discharged with aspirin and ticagrelor. He has been followed outpatient and remains asymptomatic.