Case Presentation: A 62-year-old male with RBBB, hypertension, diabetes, and former tobacco use presented with nausea, vomiting, abdominal and chest pain which responded to Pepto-Bismol. Examination revealed tachycardia, hypertension, a rigid, tender abdomen with guarding and rebound. His ECG showed anterolateral STEMI with dynamic changes. Chest and abdomen CT revealed a perforated ulcer with free air and also noted a hypodense region of the LV in the vascular distribution of the LAD suggestive of an acute infarct. Echo revealed LAD territory wall motion abnormalities with an estimated LVEF of 35%. It was decided to proceed with coronary angiography first based a multidisciplinary team discussion between the patient, surgical, and cardiology team. This showed a totally occluded proximal LAD, felt to be the culprit lesion, 90% proximal stenosis of LCx, and diffuse disease of RCA (figure). Right heart catheterization showed mixed shock. Plain old balloon angioplasty of LAD was done, IABP placed, and pressors started. He then had an exploratory laparotomy with lysis of adhesions and Graham patch repair of perforated gastric ulcer. He ultimately had a DES to his LAD 15 days after tolerating DAPT. Repeat Echo done after 2 months of GDMT revealed a recovered LVEF of 55%. Discussion: STEMI and perforated viscus are two clinical emergencies with high mortality. Few case reports of simultaneous occurrence are documented in the literature with no guideline-directed management given the rarity of its presentation. In our patient, we preceded with coronary angiogram to attain moderate hemodynamic stability with POBA aiding in revascularization and IABP providing mechanical support. Furthermore, early revascularization in STEMI is known to have mortality benefits. Our approach led to a favorable outcome with resultant recovery in cardiac performance and can be considered as a strategy to tackle similar presentations with expert deliberation.