A 62-year-old man was brought to Emergency Department for severe chest tightness of sudden onset, lasting 30 min. He had experienced episodes of chest tightness unrelated to exertion for one year. About one week prior, the frequency of these episodes had increased from 2-3/week to 4-5/week. Past medical history was significant for diabetes mellitus and hypertension for over ten years. He also had TIA about one year ago. He had been on peritoneal dialysis for one and a half years due to end-stage renal disease (ESRD), presumably related to diabetic nephropathy. On physical examination, he was afebrile, obese, and in no respiratory distress. BP measured 110/70 mmHg, PR 80/min, and RR 16/min. Except for a loud S4, cardiac and pulmonary findings were unremarkable. ECG showed ST depression in I, II, III, aVF, and V2-V6, and T inversion in III, aVF, and V3-V6. Notably, there was accompanying ST elevation in aVR ≥ 1mm, suggesting extensive subendocardial myocardial ischemia/infarction (NSTEMI). Hb was 10.8 g/mL, and liver enzymes and electrolytes were within normal limits. Tn-I and CK-MB were elevated within 3 hours after arrival (0.41 to 8.5 [N <0.5] ng/mL and 10 to 21.5 [N <5] ng/mL, respectively). Chest X-ray illustrated obesity with lung markings slightly increased in both lower lung fields. Subsequent cardiac catheterization with coronary angiography revealed preserved LV systolic function and severe triple vessel disease with LM ostium 30-40% narrowing, LAD-mid 100% stenosis, LCX-proximal 80% stenosis, LCX-mid 80% stenosis, LCX-OM1 80% stenosis, RCA-mid 90% stenosis, RCA-PDA 90% stenosis. Based on these findings, following acute management for NSTEMI, surgical consultation for CABG aimed at total revascularization was obtained.