Case Description: 69-year-old male with a history of factor VII deficiency and coronary artery disease (CAD) with a stent in the distal left anterior descending (LAD) artery, underwent diagnostic laparoscopy for suspected appendiceal carcinoma. He is a non-smoker, has good exercise tolerance and takes aspirin only three times a week, due to epistaxis. Post-surgery, he complained of 10/10 substernal chest pain. Initial troponin (TnI) was 0.11 ng/dL, peaking at >80 ng/dL in 2 hours. EKG was compatible with an anterior wall STEMI. An emergent coronary angiogram showed a patent distal LAD stent and a 99% occlusive lesion in the mid-LAD, which was treated with a drug-eluting stent. With careful clinical judgment and hematology consultation, dual antiplatelet therapy was continued despite a history of coagulopathy. On probing, it was discovered that the patient received two doses of recombinant factor VII (rVII) prior to the surgery to reduce operative bleeding. Discussion: Recombinant factor VII is known to cause serious arterial and venous thromboembolic events. This risk increases to almost 10% in patients who are elderly with concomitant vascular disease. In our patient with prior history of CAD and in the setting of acute surgical stress, exogenous factor VII unbalanced the coagulation system leading to a STEMI. Surgical teams should be aware of the detrimental consequences of administration of rVII in high cardiovascular risk patients and seek alternative hemostatic strategies. Prothrombotic agents should be used with caution and close monitoring for acute coronary syndromes, especially in patients with a high risk of CAD.