Triple-vessel Coronary Artery Disease Research Articles

Real-World Outcomes of Revascularization Strategies in Patients With Left Ventricular Dysfunction and Three-Vessel Coronary Disease Stratified by Mitral Regurgitation.

Aims: Limited information exists regarding optimal revascularization options for patients with triple-vessel coronary artery disease (TVD), heart failure (HF), and different degrees of mitral regurgitation (MR). Thus, we aimed to compare the effect of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) surgery in the indicated patients.Methods and Results: In the real-world prospective study, 1190 patients with multi-vessel disease and decreased left ventricular systolic function but without severe MR, who underwent PCI or CABG, were enrolled and followed-up for 4.7 ± 1.8 years. The primary endpoint was a composite of cardiovascular death and HF hospitalization. Secondary endpoints were the individual components of the primary outcome. Risk of the primary endpoint was higher in the PCI than in the CABG group (HR = 1.38, 95%CI: 1.14–1.67, and P < 0.01), particularly in patients with moderate MR (HR = 1.85, 95%CI: 1.35–2.55, and P < 0.01). In patients with no-mild MR, the risk of the primary endpoint did not differ significantly between PCI and CABG (P = 0.09). Treatment with PCI was associated with an increased risk for cardiovascular death and HF hospitalization in the moderate MR cohort, while PCI was comparable to CABG in the no-mild MR cohort.Conclusions: In this real-world study, for patients with HF and TVD, CABG was related to lower adverse outcome rates compared to PCI. Assessment of MR can aid in selecting optimal revascularization therapies and in risk stratification.

A two-stage classification model integrating feature fusion for coronary artery disease detection and classification

According to the World Health Organization, Coronary Artery Disease (CAD) is a leading cause of death globally. CAD is categorized into three types, namely Single Vessel Coronary Artery Disease (SVCAD), Double Vessel Coronary Artery Disease (DVCAD), and Triple Vessel Coronary Artery Disease (TVCAD). At present, angiography is the most popular technique to detect CAD that is quite expensive and invasive. Phonocardiogram (PCG), being economical and non-invasive, is a crucial modality towards the detection of cardiac disorders, but only trained medical professionals can interpret heart auscultations in clinical environments. This research aims to detect CAD and its types from PCG signatures through feature fusion and a two-stage classification strategy. The self-developed low-cost stethoscope was used to collect PCG data from a local hospital. The PCG signals were preprocessed through an iterative signal decomposition method known as Empirical Mode Decomposition (EMD). EMD decomposes the raw PCG signal into its constituent components called Intrinsic Mode Functions (IMFs). Preprocessed PCG signal was generated exclusively through combining those signal components that contain high discriminative characteristics and less redundancy. Next, Mel Frequency Cepstral Coefficients (MFCCs), spectral and statistical features were extracted. A two-stage classification framework was devised to identify healthy and CAD types. The first stage framework relies on the fusion of MFCC and statistical features with the K-nearest neighbor classifier to predict normal and CAD cases. The second stage is activated only when the first stage detects CAD. The fusion of spectral, statistical, and MFCC features was employed with Support Vector Machines classifier to categorize PCG signatures into DVCAD, SVCAD, and TVCAD classes in the second stage. The proposed method yields mean accuracy values of 88.0%, 89.2%, 91.1%, and 85.3% for normal, DVCAD, SVCAD, and TVCAD, respectively, through 10-fold cross-validation. Comparative analysis with existing approaches confirmed the reliability of the proposed method for categorizing CAD in general clinical environments. The proposed model enhances the diagnosis performance by providing a second opinion during the medical examination.

TCTAP C-056 Triple Vessel Coronary Artery Disease Involving Distal Left Main, CTO LAD, and Ostial LCX in An Elderly Patient : Challenges and Strategy

TCTAP C-056 Triple Vessel Coronary Artery Disease Involving Distal Left Main, CTO LAD, and Ostial LCX in An Elderly Patient : Challenges and Strategy

TCTAP C-012 Primary Angioplasty of Severely Calcified Right Coronary Artery in a Triple Vessel Coronary Artery Disease Patient Using Antegrade Wire Escalation Technique

TCTAP C-012 Primary Angioplasty of Severely Calcified Right Coronary Artery in a Triple Vessel Coronary Artery Disease Patient Using Antegrade Wire Escalation Technique

Bilateral Orthotopic Lung Transplantation after Resection of Benign Solitary Fibrous Tumor in the Donor Lung

IntroductionSolitary fibrous tumor (SFT) of the pleura is a rare soft tissue tumor of mesenchymal origin. Transplantation of donor lung with SFT has not been reported in the literature. We report the first case of a bilateral orthotopic lung transplantation utilizing donor lung which had SFT in the left lung.Case ReportThe donor was a brain dead 25 year old male who suffered from subarachnoid hemorrhage. He had no other comorbidities. The recipient is a 59 year old male with end stage fibrosing interstitial lung disease consistent with usual interstitial pneumonia (UIP) who was listed for bilateral orthotopic lung transplantation. His other comorbidities included triple vessel coronary artery disease, hypertension and type 2 diabetes mellitus. During the lung harvest, it was noted that the left lung had a circumferential 1 centimeter reddish appearing nodule in the left upper lobe. A stapled wedge resection of this nodule was performed during back table dissection. Pathology showed benign solitary fibrous tumor with 1 centimeter negative margins. The recipient underwent BOLT and 3 vessel coronary artery bypass grafting (CABG) on cardiopulmonary bypass via a thoracosternotomy (Clamshell). Post-operative course was uneventful and the patient was discharged home on post operative day 15. He continues to do well and symptom free at 1 year follow up. He underwent chest computed tomography (CT) scan 6 months and 1 year and there were no lung lesions identified.SummaryBilateral Orthotopic Lung Transplantation can be successfully be performed when utilizing donor lungs with benign tumors like solitary fibrous tumor. Regular follow up with CT scans is a necessary surveillance study to ensure there is no tumor recurrence. Solitary fibrous tumor (SFT) of the pleura is a rare soft tissue tumor of mesenchymal origin. Transplantation of donor lung with SFT has not been reported in the literature. We report the first case of a bilateral orthotopic lung transplantation utilizing donor lung which had SFT in the left lung. The donor was a brain dead 25 year old male who suffered from subarachnoid hemorrhage. He had no other comorbidities. The recipient is a 59 year old male with end stage fibrosing interstitial lung disease consistent with usual interstitial pneumonia (UIP) who was listed for bilateral orthotopic lung transplantation. His other comorbidities included triple vessel coronary artery disease, hypertension and type 2 diabetes mellitus. During the lung harvest, it was noted that the left lung had a circumferential 1 centimeter reddish appearing nodule in the left upper lobe. A stapled wedge resection of this nodule was performed during back table dissection. Pathology showed benign solitary fibrous tumor with 1 centimeter negative margins. The recipient underwent BOLT and 3 vessel coronary artery bypass grafting (CABG) on cardiopulmonary bypass via a thoracosternotomy (Clamshell). Post-operative course was uneventful and the patient was discharged home on post operative day 15. He continues to do well and symptom free at 1 year follow up. He underwent chest computed tomography (CT) scan 6 months and 1 year and there were no lung lesions identified. Bilateral Orthotopic Lung Transplantation can be successfully be performed when utilizing donor lungs with benign tumors like solitary fibrous tumor. Regular follow up with CT scans is a necessary surveillance study to ensure there is no tumor recurrence.

The Effects of Aortic Clamping Strategy on Myocardial Protection and Early Postoperative Outcomes During Coronary Artery Bypass Grafting Operations.

The purpose of the present study was to compare the effects of two different clamping strategies for the construction of the proximal aortocoronary anastomoses on myocardial protection and postoperative outcomes during coronary artery bypass grafting (CABG) operations. In this retrospective study, we examined prospectively collected data of patients who underwent CABG for a 3-year period. Two hundred consecutive patients, who were diagnosed with triple vessel coronary artery disease (CAD), were selected and divided into two groups. In Group 1 (single clamp) (N = 100), venoaortic proximal anastomoses were performed using a single aortic cross-clamp, while in Group 2 (double clamp) (N = 100), proximal anastomoses were performed by using an aortic side clamp. Operative and postoperative outcomes of the patients were compared between the two groups. The serum levels of myocardial damage biomarkers, creatine phosphokinase-MB (CPK-MB), and high sensitive Troponin (hsTnI) results were measured preoperatively, intraoperatively, and postoperatively (6, 12, 24, and 48 hours). Patient demographics and characteristics were similar between the two groups. In Group 1, cross-clamp duration time (65 min versus 49 min; P = .0001) was longer. However, perfusion time (91 min versus 85 min; P = .61) was similar between the two groups. In Group 2, postoperative CK-MB levels were significantly higher intraoperatively (P = .18), 6 hours (P = .22), 24 hours (P = .001), and 48 hours (P = .001) than in Group 1. HsTnI was only significantly higher in Group 2 versus Group 1 at 24 hours (P = .001) and 48 hours (P = .01) postoperatively. Time of intensive care unit stay, duration of extubation, and length of hospital stay were similar in both groups. The technique used for proximal anastomosis has a significant effect on perioperative results, especially on myocardial protection.

COMPARISON OF THE EFFECT OF ANTEGRADE AND ANTEGRADE/RETROGRADE CARDIOPLEGIA ON THE OUTCOME OF CORONARY ARTERY BYPASS GRAFT SURGERY FOR SEVERE CORONARY ARTERY DISEASE

Objective: To compare the early outcome of Coronary Artery Bypass Graft surgery using a combination of antegrade and retrograde cardipoplegia with that utilizing antegrade cardioplegia alone in triple vessel coronary artery disease.&#x0D; Study Design: Comparative cross-sectional study.&#x0D; Place and Duration of Study: Department of Adult Cardiac Surgery of Armed Forces Institute of Cardiology and National Institute of Heart Diseases, Rawalpindi, from Sep 2013 to Apr 2019.&#x0D; Methodology: A total of 160 patients with triple vessel coronary artery disease who underwent CABG surgery for 90% or greater stenos is in at least one major vessel in each of the three territories, namely the left anterior descending, the circumflex and the right coronary artery were investigated retrospectively. These were divided into 2 equal groups on the basis of the technique of administration of cardioplegia: in group-1 only ante grade blood cardioplegia was administered for myocardial protection and group-2 was given ante grade and retrograde cardiolplegia. Clinical outcomes like peri-operative mortality and morbidity were recorded, and serum creatine kinase MB, lactate, and mixed venous oxygen saturation levels were monitored. Two dimensional echocardiogram was performed on the 6th post-operative day and follow-up visits were planned 1 week and 4 weeksafter discharge from hospital.&#x0D; Results: There were 2 (2.5%) early deaths in group-1 and no peri-operative mortality in group-2. Five patients in group-1 (6.25%) and 2 (2.5%) in group-2 had non-fatal peri-operative myocardial infarction. However, significant differences included increased incidence of intra-operative ventricular dysrythmias, higher CK-MB levels at 24 hours after surgery, and increased requirement of intra-aortic balloon pump and inotropic support in Group-1.&#x0D; Conclusion: We conclude from this study that the combined delivery of ante grade and retrograde cardioplegia during CABG surgery for triple vessel coronary artery disease provides better myocardial protection and hence better outcome than antegrade cardioplegia alone.Keywords: , , ,

Coexistent atherosclerotic renal artery and lower limb peripheral artery disease in patients with symptomatic triple vessel coronary artery disease

Coexistent atherosclerotic renal artery and lower limb peripheral artery disease in patients with symptomatic triple vessel coronary artery disease

Independent predictors of in-hospital and 1-year mortality rates in octogenarians with acute myocardial infarction.

Older age is known as a negative prognostic parameter in acute myocardial infarction (AMI) patients. In this study, we aimed to explore age-associated differences in treatment protocols, in-hospital and 1-year mortality. This cohort observational study included 277 consecutive AMI patients, separated into 2 groups according to whether their age was ≥80 years or not. We found that group I patients (aged ≥80 years) had a notably lower rate of percutaneous coronary intervention (PCI) performed (P < 0.0001) and a notably higher in-hospital death rate (P < 0.003). The multivariate logistic regression analysis found that three variables were independent predictors of in-hospital mortality: age ≥80 years (P < 0.0001), LVEF <40% (P < 0.0001), and Killip class ≥3 (P < 0.0001). The 1-year death rate was again significantly higher in group I patients (P < 0.001) and was independently predicted by the triple-vessel coronary artery disease (P = 0.004) and an LVEF <40% at admission (P = 0.001). The 1-year readmission rate was superior in group I (P < 0.01) and independently predicted by an age ≥80 years (P < 0.001), and an history of congestive heart failure (P < 0.0001) or permanent atrial fibrillation (P < 0.001). We concluded that patients aged ≥80 benefit less often from a PCI and have higher rates of in-hospital mortality, as well as of 1-year readmission and mortality rates.

Complex regional pain syndrome (reflex sympathetic dystrophy) after coronary artery bypass graft – An interesting case

A 58-year-old male presented himself with swelling, pain, and color change of the left shoulder, arm, and hand of 3 months duration. His problems started a week after he underwent a coronary artery bypass graft for triple-vessel coronary artery disease. The function of the left upper limb was severely restricted. Investigations done to know the cause of his problems were negative. A clinical diagnosis of complex regional pain syndrome was made. Even though this syndrome was observed after myocardial infarction, its occurrence after CABG has been quite rare. This case is presented as CABG is on the rise, and more and more cases may occur which should not be missed.

Life Threatening Reactive Left Ventricular Hypertrophy Due to Increased Blood Flow after Coronary Artery Bypass Grafting

A 68-year-old patient with triple vessel coronary artery disease was scheduled for elective coronary artery bypass grafting. Three days after the uneventful surgery, the patient went into cardiogenic shock, which was deemed to be caused by a dynamic left ventricular outflow tract obstruction and high-grade mitral regurgitation, which both had not been present before surgery. On an emergency basis, surgical transvalvular septal myectomy and mitral valve replacement were performed. After initial extra corporeal membrane oxygenation (ECMO) therapy and a prolonged (intensive care unit) ICU stay the patient finally recovered and is well one and a half years after surgery.

Low dose interleukin-2 in patients with stable ischaemic heart disease and acute coronary syndrome (LILACS)

Abstract Background Regulatory T lymphocytes (Tregs) are critical for immune homeostasis. Pre-clinical models have demonstrated that Tregs can modulate post-ischaemic immune responses and promote myocardial healing. Patients with ischaemic heart disease (IHD) display reduced anti-inflammatory Tregs and increased pro-inflammatory effector T cells (Teffs). Low-dose interleukin-2 (ld-IL2) has been shown to increase Tregs in patients with autoimmune diseases but is currently contraindicated in patients with IHD. Purpose To assess the safety and pharmacodynamic effect of ld-IL-2 in patients with IHD. Methods LILACS was a prospective, randomised, double-blind, placebo-controlled, dose-escalation, Phase I/II clinical trial, which tested ld-IL-2 (aldesleukin) given once daily subcutaneously, for five consecutive days. In Part A, 25 patients with stable IHD were randomised (drug:placebo ratio of 3:2) in 5 dose groups (0.3, 0.6, 1.2, 2.4 and 3x106 IU/day); whilst in Part B, 16 patients with non-ST elevation myocardial infarction (NSTEMI) were randomised (drug:placebo ratio of 6:2) in two dose groups (1.5 and 2.5x106 IU/day). Follow up was performed the day after dosing and again 7 days later. Doses were determined after blinded review. An independent committee reviewed unblinded data prior to commencing Part B. The primary endpoint was safety in parts A and B. Additionally in Part B, a co-primary endpoint was to calculate the dose required to increase Tregs by 75%. [NCT03113773] Results Ld-IL2 was well tolerated for all dose groups with the commonest adverse events being mild injection site reactions. Two serious adverse events, not considered to be drug related, occurred in Part B – one prior to dosing and resulting in withdrawal. The other was a recurrent NSTEMI after dosing ended in a patient with severe triple vessel coronary artery disease awaiting urgent bypass surgery. In Part A, Tregs increased with dose escalation whilst no Teff increases were noted (Figure 1A). In Part B, patients treated with 1.5 and 2.5x106 IU/day doses had a median increase in Tregs of 80.5% (CI 36.2–124.7%, p=0.003) and 108.3% (CI 55.3–161.3%, p=0.002) respectively (Figure 1B). A linear regression model estimated an increase of 43.3% (CI 23.6–63.0%, p=0.0003) per unit dose. The estimated dose to achieve a 75% increase in Tregs was 1.46x106 IU/day (CI 1.06–1.87). No increase in Teffs cells were seen however, a dose-dependent decrease was measured in B cells, whilst NK cells and eosinophils increased at the top 2.5 and 3x106 IU/day dose. A panel of 29 cytokines and chemokines showed a dose-dependent type 1 and 2 cytokine response. Single-cell RNA sequencing was performed on immune cells before and after dosing. Conclusions Ld-IL2 was safe and well-tolerated. An induction dose of 1.5x106 IU per day for 5 days provided an effective expansion of Tregs without increasing Teffs. This work provides important data for the future therapeutic use of ld-IL-2 which is ongoing. Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): Medical Research Council, British Heart Foundation Cambridge Centre of Excellence

Familial Hypercholesterolaemia With Premature Coronary Artery Disease: A Case Report

A young, 18-year-old lady presented with history of chest pain on exertion typical of angina. General examination revealed multiple tendon xanthomas. Systemic examination was unremarkable. Electrocardiogram showed segment (ST) depression in inferior and lateral leads. Echocardiogram revealed normal left ventricular systolic function and no left ventricular regional wall motion abnormalities. Diastolic flow turbulence was noted in the left main coronary artery and proximal left anterior descending artery on color Doppler interrogation across the coronary arteries. Lipid profile showed unusually high total cholesterol and low-density lipoprotein cholesterol. Subsequent evaluation with coronary angiogram revealed triple vessel coronary artery disease. The patient underwent coronary artery bypass surgery and is on antiplatelet and lipid-lowering drug therapy.

High-Risk "Protected" Percutaneous Coronary Intervention with Mechanical Circulatory Support in a Non-Surgical Center - An Early Asian Experience.

High-risk "protected" percutaneous coronary intervention (PCI) using mechanical circulatory support (MCS) devices, particularly the Impella axial pump, has emerged as a viable treatment option for high-risk patients with satisfactory clinical outcomes. High-risk and complex interventions have mostly remained within the domain of surgical centers. We report on an early "protected" PCI experience using MCS with the Impella flow pump at a high-volume PCI hospital without on-site surgery. A total of 5 patients underwent elective "protected" PCI utilizing MCS with Impella at our institution. The mean left ventricular ejection fraction was 28 ± 10% and all patients had triple vessel coronary artery disease with the majority having a high SYNTAX score. Device implantation and procedural success were achieved in all cases with no intraprocedural or access site complications. All patients were alive at 30 days and clinically well. The Impella unloads the ventricle, improves forward cardiac output and lowers myocardial oxygen demand, thereby improving mean arterial pressure and coronary perfusion. Device insertion is relatively quick and the "learning curve" is short, centering mainly around managing large bore access. Our limited experience suggests that not only is high-risk PCI with Impella support feasible in a non-surgical center, but that it may be crucial to enable success.

Left brachial artery: one more way to percutaneous insertion of IMPELLA 2.5L circulatory support for high-risk percutaneous coronary intervention - a case report.

BackgroundPercutaneous circulatory support allows the performance of coronary interventions in ever more complex anatomic and clinical situations. The large-bore systems currently available need a suitable vascular calibre to be inserted restricting percutaneous access mainly to the common femoral artery.Case summaryWe present the case of a 64-year-old man, admitted with an acute coronary syndrome and congestive heart failure, due to triple-vessel coronary artery disease with left main involvement and left ventricular dysfunction. He was successfully treated with percutaneous coronary intervention (PCI) supported through an IMPELLA 2.5L circulatory system. Concomitant severe and diffuse peripheral vascular disease did not allow femoral insertion of the circulatory support which was therefore successfully introduced through a left brachial percutaneous approach.DiscussionTo the best of our knowledge, this is the first report of a brachial, percutaneous placement of the IMPELLA 2.5L system to support a high-risk PCI procedure. In appropriately selected patients, this approach could be an option when common vascular accesses are not available.

Case Report: Ramipril and microscopic colitis; a necessary tool of cardiologists can rarely be devastating for patients

Angiotensin converting enzyme inhibitors could lead to severe diarrhoea related to microscopic colitis. Few of such cases have been reported before and this serious problem, from a widely used class of drugs in hypertension and heart failure, needs to be more recognised. We describe the case of collagenous colitis related to ramipril use in the following case report. A 74-year-old farmer who had a history of triple vessel coronary artery disease was admitted to district general hospital with non-ST elevation myocardial infarction. He had known alcohol-related chronic pancreatitis with chronic diarrhoea as a complication, which was managed with pancreatic enzyme replacement therapy. However, he developed severe worsening of diarrhoea causing bowel incontinence and nocturnal symptoms during his admission to hospital. The explosive and watery nature of diarrhoea with urgency was so troublesome that it delayed coronary revascularisation and lead him to have significant psychological distress and low mood while nocturnal bowel motions meant he was unable to sleep. He was compliant with his pancreatic enzyme replacement therapy during this period. Infective causes were ruled out by stool microbiology examination and coeliac disease by oesophagogastroscopy and biopsy. It was noticed that he was recently prescribed ramipril that was later stopped as a possible diarrhoea trigger. Diarrhoea started settling immediately and resolved to his baseline within a week. A colonoscopy was performed in the meantime and biopsies demonstrated microscopic colitis (MC). He did not tolerate budesonide well so was stopped. However, a follow-up colonoscopy with biopsy in two months showed resolution of MC.

Cardiac Imaging—Physiologic Assessment of Coronary Artery Lesion

AbstractThirty percent of angiographically significant coronary lesions may be functionally significant. Physiological assessment is essential to treat intermediate coronary lesions before taking the decision for percutaneous intervention. Even when coronary artery bypass is planned as treatment modality in triple-vessel coronary artery disease, the SYNTEX II trial has shown that functionally significant lesion treatment by bypass grafts improves the outcome of these patients. In this article, possible ways of estimating the physiologic assessment of coronary lesion, and the advantages and disadvantages of methods of estimating the physiologic assessment of coronary lesions is discussed.

Coexisting Coronary and Carotid Artery Disease - Which Technique and in Which Order? Case Report and Review of Literature.

Coexisting carotid artery stenosis and coronary artery disease is common and there is currently no consensus in treatment guidelines on the timing, sequence and methods of revascularization. We report a case of a patient with symptomatic triple vessel coronary artery disease as well as asymptomatic severe right internal carotid artery stenosis. Our patient underwent myocardial revascularization first, because she presented with unstable angina and was asymptomatic neurologically. This article summarizes current literature about the approach to carotid and coronary artery revascularization and addresses the decision-making process regarding the timing and sequence of revascularization.

Uticaj metaboličkog sindroma na koronarografske karakteristike osoba sa prebolelim infarktom miokarda

Introduction: Previous epidemiological and clinical studies confirmed the relation between metabolic syndrome and an increased risk of coronary artery disease (CAD). There was a significant correlation between the syndrome and more severe angiographic lesions in the coronary arteries of these patients. Objective: We aimed at investigating the importance and influence of the metabolic syndrome on the severity of the angiographic lesions in the coronary arteries of the patients with myocardial infarction. Method: The research included 143 participants with a myocardial infarction, of whom 81 (58.7±6.2) had metabolic syndrome and 62 (54.9±10.3) were without it (p 0,05), triple-vessel CAD 65,4% vs 21,0% (p<0,001), multi-vessel CAD 91,3% vs 53,2% (p<0,001). When we compared the affected coronary arteries of the patients with MS and those without MS we found: LAD 88,9% vs 71,0% (p<0,01), LCx 64,2% vs 29,0% (p<0,01), RCA 80,2% vs 61,3% (p<0,01), LM 14,8% vs 1,6%. Conclusion: Patients with MS had more severe coronary artery lesions, with a higher incidence of triple-vessel and multi-vessel disease, as well as stenosis of LAD, LCX. RCA, LM, when compared to those without MS. This clearly indicates MS is a significant risk factor for more severe CAD.

Triple-Vessel Coronary Artery Disease Associated with Familial Hyperhomocysteinemia

Homocysteine is a sulfhydryl containing amino acid implicated in the pathogenesis of cardiovascular disease in multiple epidemiologic studies. However, elevated homocysteine in isolation is not known to lead to severe coronary artery disease requiring emergency intervention. We report a previously asymptomatic 55-year-old gentleman who presented with an acute myocardial infarction with bradycardia and was found to have triple-vessel coronary artery disease on angiography. After stabilization, he underwent a coronary artery bypass grafting in view of the severity of disease. A thorough evaluation revealed the absence of all traditional risk factors except elevated serum homocysteine. The evaluation of family members also revealed elevated homocysteine levels in both his sons and wife. Mutation testing of the methylenetetrahydrofolate reductase (MTHFR) gene showed homozygous Q429A mutation in the patient and heterozygous A222V and Q429A mutation in both his sons. The patient was discharged successfully and is well after 9 months of follow-up. Homocysteine has been implicated in the pathogenesis of cardiovascular disease in synergy with other traditional risk factors. This is a rare presentation of familial hyperhomocysteinemia presenting with severe coronary artery disease and elevated homocysteine levels in all family members. Elevated homocysteine levels in isolation may lead to significant cardiovascular disease and should be checked if no other risk factors are present. It may be useful to screen the patient and family members for underlying MTHFR mutations. In the absence of prospective evidence, there appears to be little harm in providing multivitamins to attempt to reduce homocysteine levels.