Managing Acute STEMI in the Setting of Immune Thrombocytopenic Purpura: A Therapeutic Dilemma.

BACKGROUND: Immune thrombocytopenia (ITP) is an autoimmune condition characterized by thrombocytopenia. Despite bleeding tendencies, patients with ITP face thrombotic risks. Acute coronary syndrome in ITP is uncommon and poses a management dilemma between antithrombotic therapy and the high bleeding risk. CASE SUMMARY: A 43-year-old man with severe ITP (platelet nadir 1 × 103/μL) treated with avatrombopag presented with inferoposterior ST-elevation myocardial infarction (STEMI). Angiography showed occlusion of the right posterolateral ventricular branch and right posterior descending artery. Plain old balloon angioplasty was performed without stenting. He remained stable without bleeding and was discharged on dual antiplatelet therapy, avatrombopag, and prednisolone. DISCUSSION: ITP presents a clinical paradox of concurrent bleeding and clotting risks. Managing STEMI requires balancing these competing mechanisms. TAKE-HOME MESSAGES: Thrombocytopenia in ITP does not protect against acute coronary syndrome. Navigating the balance between bleeding and clotting following a STEMI event requires a tailored, flexible approach.