CASE REPORT PEER REVIEWED | OPEN ACCESS www.edoriumjournals.com International Journal of Case Reports and Images (IJCRI) International Journal of Case Reports and Images (IJCRI) is an international, peer reviewed, monthly, open access, online journal, publishing high-quality, articles in all areas of basic medical sciences and clinical specialties. Aim of IJCRI is to encourage the publication of new information by providing a platform for reporting of unique, unusual and rare cases which enhance understanding of disease process, its diagnosis, management and clinico-pathologic correlations. IJCRI publishes Review Articles, Case Series, Case Reports, Case in Images, Clinical Images and Letters to Editor. Website: www.ijcasereportsandimages.com Is 20s too young to have triple coronary vessel disease? M. Umair Bakhsh, Hassan Alkhawam, Feras Zaiem, Jaspirt Takher, Anirudh Pareek, Mohammed El-hunjul, Robert Sogomonian, Neil Vyas ABSTRACT Introduction: Coronary artery disease (CAD) remains the leading cause of death in the US in both men and women. This is less frequent in younger population, however, when present CAD can have devastating consequences on the patient and the family. Case Report: We reported a case of a 28-year-old smoker male with a family history of CAD who presented with dyspnea on exertion. Laboratory examinations were normal for cardiac enzymes and negative for D-Dimer. On admission ECG showed sinus rhythm at 71 bpm, RSR’ in V1, S wave in I, Q wave in III, T wave inversion in III. Echocardiogram showed right ventricular systolic function reduced mid portion, preserved at apex and base (McConnell’s sign) consistent with acute pulmonary embolism. Patient was started on anticoagulation. Computed tomography angiography (CTA) was also done which was negative for any acute pulmonary embolism, and anticoagulation was discontinued in the light of negative CTA. The patient was discharged from hospital with follow-up in outpatient department. However, the patient came back to emergency department with worsening dyspnea. Lab work was signifcant for elevated troponin I and ECG on admission showed normal sinus rhythm and S1Q3T3 pattern. Patient had coronary angiography which showed three vessel disease. Conclusion: Smoking is conventionally recognized as the most common risk factor for heart disease. The CAD in young adults has a poor long-term prognosis. Smoking cessation remains a signifcant challenge in younger population. More awareness and cessation measures are required to address this emerging situation. Given lack of warning signs in these patients, physicians need to be more aggressive in managing risk factors as CAD in younger patient can have adverse outcomes. (This page in not part of the published article.)