A 38-year-old man was admitted because of having abdominal fullness associated with progressive SOB (PND and orthopnea) for ten days. He denied having abdominal pain, chest pain/tightness, fever, cough, or palpitations. Before admission, the local physician noted elevated liver enzymes with normal AFP and negative hepatitis markers (hepatitis B or C) and splenomegaly on abdominal ultrasound. He was a heavy smoker. Family history was negative for diabetes mellitus but strongly positive for atherosclerotic coronary heart disease (CHD) with prior myocardial infarction (MI) (parents, two brothers, and one sister). On admission, he was moderately obese, afebrile, and mentally alert in moderate respiratory distress (BP 124/77 mmHg, RR 20/min, and PR  106/min). There were physical signs of biventricular heart failure (HF) (JVD with JVP 11 cm H2O, bilateral crackles with percussion dullness at posterior lower 1/3 of the right lung field, PMI shifted to the left, apical S3 and a Gr 2/6 systolic murmur which increased in intensity with inspiration). The ECG showed Q in II, III, aVF, and V2-V4, suggesting inferior and anterior MI of undetermined age. The chest X-ray confirmed cardiomegaly, and echocardiography showed marked LV enlargement and global LV hypokinesis (LVEF 25%) with regional wall motion abnormalities in anteroseptal, apical and inferior segments, moderate MR, and severe TR. Pertinent laboratory data included Hb 14.1 g/dL, WBC 12,100 /uL, BNP, 1780 (N: 400) pg/mL, Tn-I: 0.92-0.76 [N <0.12] ng/mL, CK-MB: 1.9 [N <5.0] ng/mL, Alk-phosphatase 94 IU/L, ALT(GPT): 469 IU/L, BUN 15 mg/dL, Cr. 1.2 mg/dL, AST(GOT): 138 IU/L. Elevation of liver enzymes was attributed to liver congestion as they declined following the improvement of HF. Because the critical time window (counting from the onset of symptoms) had passed, the care team deferred primary PCI. After treatment of HF, subsequent coronary angiography revealed severe triple vessel atherosclerotic CHD (LAD: total occlusion, LCx-distal: 70% stenosis; LCx-OM1: total occlusion, RCA-Mid: total occlusion, collateral circulation: LCx collateral to LAD and RCA). Accordingly, the patient was referred for surgery (i.e., CABG for complete revascularization).