CASE PRESENTATION: A 58 y/o Caucasian male with a PMH significant for HTN, non-valvular atrial fibrillation and recent embolic stroke on rivaroxaban, biologic aortic valve replacement presented with sudden onset of sub-sternal chest pain. On exam, he was diaphoretic, tachycardic with irregular pulse, and faint crackles were heard over both of his lung bases. His EKG on admission showed atrial fibrillation with RVR and 1mm ST depressions in leads V5-V6 . Troponin I on admission was elevated at 0.08. His initial management included sublingual nitroglycerin, iv metoprolol and rivaroxaban was continued. His troponin levels however trended up to 9.56 at 12hrs. Repeat EKG remained unchanged. Heparin drip was started and subsequent cardiac cath showed a complete occlusion in the distal left circumflex artery with angiographic appearance of an embolus followed by successful embolectomy; he did not have any significant atherosclerotic disease in his other vessels. Given these findings, a post cardiac-cath TEE was done which revealed a new left atrial appendage clot which wasn’t present on a prior TEE done after his ischemic stroke few months ago. He was started on Coumadin and eventually discharged home on dual antiplatelet agents aspirin and clopidogrel.