We presented a case of a 60 year old male with history of HTN, HLD, GERD and PE who presented for intermittent chest pain for 3 days that he described as tightness and pressure over his sternum. It does radiate up to his neck and is made worse by exertion. Family history of MI in his father in his early 50s. His cath revealed 100% stenosis due to thrombotic lesion in the mid-Cx. He was discharged but returned 2 days later due to sudden severe shortness of breath, chest pressure and no improvement with nitroglycerin, he had a new harsh systolic murmur across his precordium and was diagnosed with new severe mitral regurgitation secondary to papillary muscle rupture. He was taken urgently to he cath lab after intra-aortic balloon pump placed for mitral valve replacement.