Right Coronary Artery Thrombosis Causing ST-Elevation Myocardial Infarction After a Coronary Artery Disease Reporting and Data System Score of 0, With Disseminated Intravascular Coagulation During Idiopathic Acute Pancreatitis: A Case Report.

Acute pancreatitis may cause electrocardiographic abnormalities and troponin elevation that mimic acute myocardial infarction. True coronary thrombosis is less common. The development of disseminated intravascular coagulation shortly after percutaneous coronary intervention creates a difficult balance between bleeding control and prevention of early stent thrombosis. A 68-year-old man with no previous pancreatitis presented with acute interstitial pancreatitis. Evaluation did not identify biliary disease, alcohol use, hypertriglyceridemia, hypercalcemia, medication exposure, autoimmune pancreatitis, pancreatic duct abnormalities, or malignancy, and the episode was classified as idiopathic. Coronary CT angiography performed five months earlier had shown an Agatston calcium score of 0 and Coronary Artery Disease Reporting and Data System (CAD-RADS) category 0, with no visible coronary plaque or stenosis. On day two of hospitalization, he developed inferior ST-elevation myocardial infarction caused by a 99% thrombotic subtotal occlusion of the mid-right coronary artery. Primary percutaneous coronary intervention with drug-eluting stent implantation restored normal coronary flow. Approximately 48 hours later, he developed bleeding-predominant disseminated intravascular coagulation with severe thrombocytopenia, hypofibrinogenemia, prolonged coagulation parameters, and mucocutaneous bleeding. Aspirin was continued, ticagrelor was changed to clopidogrel, and targeted blood-component replacement was administered. Acquired and inherited thrombophilia testing performed after recovery was negative. Acute pancreatitis may mimic myocardial infarction, but true coronary thrombosis should be suspected when ischemic symptoms, reciprocal electrocardiographic changes, dynamic troponin elevation, regional wall-motion abnormality, and a culprit coronary lesion are present. A recent normal coronary CT angiogram does not exclude a later acute thrombotic event. Bleeding-predominant disseminated intravascular coagulation shortly after percutaneous coronary intervention requires individualized antiplatelet adjustment and targeted hemostatic support.