The "How Should I treat Session?"is a perfect format for cases presentation with enhanced interactivity. The idea of this type of session is really to share experience and confront opinion from different operators. This format has been successfully developed during last few years during EUROPCR and is now diffused by PCR in the overall community.

　　Case presentation 

　　A 67 year-old is admitted in ourinstitution for high risk NSTEMI. Hisrisk factors include hypertension, dyslipidemia and type 2 DM and he has no previous history or coronary artery disease. He was admitted in the emergency room after 2 episodes of chest pain at rest within last few hours. Clinical examination after chest pain relief revealed high risk characteristics such as heart failure (KILLIP 2) and low blood pressure (85/50 mmHg). ECG at admission showed diffuse ST changes and ST segment elevation in aVR lead suggesting complex CAD with MVD＋/－(Figure). Left main involvement. Laboratory results showed elevation of myonecrosis biomarkers (Troponin 4.9IU) and renal failure (creatinin 116μmol/L). TTE perfomed in the emergency room showed impaired LV function (EF: 45% ) and anterior wall hypokinesia.

　　Initial Strategy

　　This patient had with many ‘high risk’ criteria related to: clinical presentation (Chest pain at rest, KILLIP 2),risk factors (Diabetic patient, CKD),Biomarkers (Positive troponin),ECG (aVR ST elevation, diffuse STchanges)TTE (Anterior Hypokinesia, impaired LV function).Accordingly, initial strategy was to send the patient ‘urgently’ to thecathlab (＜2h) following the last ESC guidelines with as adjunctive pharmacological therapy: 4000 IU UFH,250 mg aspirin and 600 mg clopidogrel. Due to hemodynamic instability of the patient, femoral access was decided in case an intra-aortic balloon pomp might be needed. Coronary angiography shows subtotal occlusion of the mid part of the LAD, a critical stenosis on a marginal branch and a CTO of the right coronary artery. The SYNTAX score was 26.

　　How would you treat him? 

　　To summarize the case, we have a‘high risk’ patient suffering from an‘high risk’ NSTEMI with a 3-VDinvolving CTO of the RCA. While it’s probably consensual that this patient deserves revascularization, we need to discuss the optimal mode of revascularization with several important questions。Timing of revascularization ? Multivessel PCI vs.‘Culprit’LAD PCIonly vs. CABG ?If PCI: Multivessel or ‘LAD only’? BMS or DES ? Adjunctive therapy?