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Case & Plan: 63 years, Male Risk Factors include Controlled Hypertension Controlled Hyperlipidemia Uncontrolled IRDM SAQ-7 score: 45, Current Smoker Presented in 1/27/2024 with AWSTEMI @OSH with hypotension and EF 30%. Cath revealed extensive 3 V CAD, pt was optimized and referred for CABG: which was declined by the family after Heart team discussion. Pt has known low EF but no documented CAD in the past: on ACEI only. Recent echo revealed EF 30-37% with small LV thrombus and placed on warfarin. ASA, Warfarin, Carvidolol, Atorvastatin, Empagliflozin, Furosemide, Albuterol (intolerant tp Entresto) Cath @ OSH on 1/27/2024 revealed 3 V CAD, syntax score 35, LVEF 32% and STS risk score 5.2%. IABP was placed post Cath which was removed after 48hrs. Heart team discussion considered pt very high surgical risk and recommended high risk Protected PCI.