Objective: To study the impact of shisha smoking on the extent of coronary artery disease. Methods: Patients who underwent coronary angiography were included in this observational cohort study and were divided to four groups according to the smoking pattern: shisha smokers, cigarettes smokers, mixed smokers (shisha and cigarettes) and non-smokers. Coronary angiography was done and the severity of coronary artery disease was defined according to Duke Jeopardy Score (DJ). Results: The study comprised of 287 consecutive patients; 22% were shisha smokers, 35% cigarette smokers, 5% mixed smokers and 38% non-smokers. Significant elevation of systolic blood pressure (p=0.009) and heart rate (p<0.001) were observed among mixed smokers followed by shisha smokers, cigarettes smokers and non-smokers respectively. The mean value of DJ score was highest among shisha smokers than mixed smokers, cigarettes smokers and non-smokers respectively (p=0.012). We also compared DJ score in shisha smokers with CAD vs nonshisha smokers with CAD and we found that 71.43% of shisha smokers had an advanced DJ score (>6) which was statistically significant (p=0.008) where shisha smokers showed significantly higher resting pulse (p<0.001) and systolic blood pressure (p=0.001) compared to nonshisha smokers and mean DJ score was significantly higher among shisha smokers (6.961±3.238) vs non-shisha smokers (5.762±3.062) (p=0.004). Conclusion: Shisha smoking is associated with severe coronary artery disease that calls for the need to enroll them in tobacco cessation courses.