We report two cases of immune thrombocytopenic purpura (ITP) associated with acute coronary artery syndrome highlighting the interventions done in every case along with the medications used during intervention and as outpatient. The first case is that of a woman with ITP exacerbation while on dual antiplatelet therapy and the second case is that of a male presenting with non-ST elevation myocardial infarction (NSTEMI) while in a thrombocytopenic crisis. In both cases antiplatelet therapy was held and thrombopoietic therapy was initiated before resuming full anticoagulation and coronary intervention. Given the paucity of data on ITP and antiplatelets treatment in the setting of acute coronary syndrome, no strict recommendations can be proposed, but antiplatelets appear to be safe acutely and in the long term in this category of patients as long as few measures are undertaken to minimize the risks of bleeding and thrombosis. 1. Case 1 A 61-year-old smoker woman was admitted to the emergency department with retrosternal localized typical acute chest pain that started three days prior to presentation. Pain occurred at rest and was associated with shortness of breath. Upon arrival to the emergency room patient was still in pain, but vital signs were stable. The heart and lung examinations were remarkable for the presence of regular heart sounds with S3 gallop as well as bilateral fine basal crackles. Neither cutaneous nor mucosal petechia nor purpura was noted. The rest of the physical exam was normal. Her past medical history was significant for two uneventful pregnancies and chronic immune thrombocytopenic purpura (ITP) currently in remission. Ten years ago ITP was refractory with relapse during steroid tapering. Subsequently splenectomy was performed, establishing remission. Laboratory blood tests revealed hemoglobin of 15？mg/dL, platelet count of 322 × 109/L, normal PT and PTT, troponin of 0.5？ng/mL, and CKMB 7.7？ng/mL. Inferior ST elevation was present on initial ECG with poor R wave progression anteriorly. She received in the emergency room nitroglycerin and morphine as well as 300？mg of clopidogrel and 325？mg of aspirin along with 5000 units of heparin bolus. Primary percutaneous coronary intervention was performed. The right common femoral artery was accessed with a 6 French sheath. Diagnostic angiography revealed acute 99% thrombotic occlusion of proximal LAD with an ejection fraction estimated at 25% on the left ventriculogram. The left circumflex and right coronary arteries were patent with right system dominance. A 6 French XBLAD 3.5 guiding
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