Introduction: Ischemic coronary heart disease is the leading cause of worldwide mortality. It has been ob-served that good control of traditional risk factors (smoking, hypertension, LDL-cholesterol, diabetes mellitus, chronic kidney disease) does not always lead to a stagnation of the disease. In recent years, a num-ber of non-traditional risk factors, independent of tho-se mentioned above, have been found: homocysteine level, lipoprotein A, uric acid. An increased level of homocysteine causes endothelial dysfunction, reduces vascular flexibility and alters the process of haemosta-sis, leading to cardiovascular disease, sometimes ra-pidly progressive, despite the optimal control of com-mon risk factors. An increase of approximately 5 μmol L of homocysteine rises cardiovascular risk by up to 20%.

Materials and methods: We present the case of a 42-year-old male, smoker, hypertensive, without PPA, hospitalized in the cardiology clinic with clinical and paraclinical picture of inferior STEMI. Coronarogra-phically is diagnosticated with bivascular coronary di-sease, treated interventional by implanting two DESs in LCX, respectively RCA. Echocardiographic, we see moderate systolic LV dysfunction, severe mitral regur-gitation and apical LV aneurysm with thrombus. Evo-lution is favorable, being discharged with maximum drug therapy and indications for lifestyle changes. Af-ter 3 months, he presented in ER with angina pecto-ris onset for 4 days. The coronary angiography detects progression of coronary artery disease, with 95% osteal stenosis in LAD, treated by implanting a DES in LMS and LAD.

Results: Echocardiographic, spectacular recovery of heart function and mitral insufficiency is observed. Considering the rapid progression of coronary artery disease under maximum drug treatment and strict control of risk factors, the plasma homocysteine dose is decided with a double normal limit outcome. The pati-ent receives supplements of folic acid and vitamin B12, and at 12 months coronarography control, the stents are well established in the arterial wall, assessed by OCT, without restenosis and progression of coronary artery disease.

Conclusions:

1. Complex coronary angioplasty with pharmacolo-gically active stent implantation in LMS and LAD, “cross-over” LCX.
2. Rapid progressive atherosclerotic disease in patient with controlled classical risk factors but with hyper-homocysteinemia
3. Great recovery of cardiac function and mitral regur-gitations after PCI.
4. Controlling the atherosclerosis process by lowering homocysteine levels by folic acid and vitamin B12 supplements.