A 55-year-old man (A. Z.) was admitted to Our Cardiac Step Down Unit of the tertiary center: Careggi Hospital, for an evaluation in the presence of a history of recurrent cardiovascular events. Classical cardiovascular risk factors: Hypertension on therapy with a good control, type 2 diabetes mellitus on metformin (3 g/day) with good glycemic control (glycated hemoglobin 5.6 %), high LDL cholesterol levels on statin treatment (rosuvastatin 20 mg/day) reaching a target of LDL 42 mg/dl; low HDL levels (24 mg/dl) on treatment, overweight (BMI 27.6). With regard to family history, almost all his relatives had suffered from a cardiovascular event (Fig. 1) at a young age. The first thrombotic event occurred at the age of 44 when he had an ischemic stroke without neurological sequelae treated with medical therapy. Aspirin therapy was spontaneously discontinued by the patient after about 4 years. At the age of 52, he had a STEMI treated with thrombolysis and subsequently underwent coronary angiography that demonstrated the presence of a critical stenosis in the right coronary artery (RCA) treated by angioplasty and drug-eluting stent (DES) implantation. One year later (on aspirin and clopidogrel), he suffered from an anterior STEMI initially treated with thrombolysis. A subsequent coronary angiography showed a critical stenosis of the left anterior descending artery (LAD), treated with balloon angioplasty and implantation of a DES on LAD and first and second diagonal branches. The course was complicated by acute intrastent thrombosis of the second diagonal branch, treated with the deployment of another DES. A few months later, a myocardial scintigraphy demonstrated signs of previous subendocardial necrosis in the mid-distal portion of the anterior wall and in the apex with mild inducible ischemia in the same area. At the age of 55—on dual antiplatelets—he had a recurrent inferior STEMI treated with thrombolysis, heparin and clopidogrel. After 1 day, a coronary angiography demonstrated a stenosis of LAD and circumflex artery and critical stenosis of RCA with image of complex plaque, which was treated with DES implantation. Previously implanted stents on first and second diagonal branches were patent. Echocardiography showed normal left chambers diameters and ventricular ejection fraction (EF 55 %) without valve diseases. The patient was then referred to our Cardiac Step Down Unit of Careggi Hospital. Because of his personal and family history, a thrombophilic screening was performed with these results: heterozygous mutations of both factor V Leiden and factor II G20210A; low levels of free protein S (52 %; n.v. \75 %); high levels of factor VIII (210 %; n.v. 60–150 %); elevated Lipoprotein(a) (893 mg/l; n.v.\300 mg/l) (Fig. 1). One month later, he was submitted to a myocardial perfusion stress test with dipyridamole, which was negative. A myocardial perfusion scintigraphy, a few months later, was positive for reversible uptake defects in LAD territory. Because of the presence of two stenoses on the LAD and the high estimated thrombotic risk, the patient was advised to undergo coronary artery bypass graft (CABG) but, after his refusal, a percutaneous coronary intervention (PCI) (triple DES implantation of the double stenosis on LAD II and on the critical stenosis of LAD III) was performed and E. Cecchi C. Giglioli Department of Heart and Vessels, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy