Chest Pain, Statins, Troponin Elevation, and Myopathy: A Diagnostic and Management Dilemma

A 64-year-old man with known ischemic heart disease and previous myocardial infarction and stent implantation presented to the Emergency Department with bilateral arm pain and chest discomfort with mixed features. He described a dull, central sensation within the chest, which did not radiate to the neck, jaw, or back. Additionally, he had a 3-week history of fatigue and intermittent myalgias, predominantly affecting the shoulders on exertion. Cardiac risk factors included hypertension and hypercholesterolemia. There was no history of diabetes mellitus, with normal baseline renal function (creatinine 80 µmol/L, estimated glomerular filtration rate >90 mL/min/1.73 m²). Regular medications included atorvastatin, olmesartan, hydrochlorothiazide, spironolactone, and allopurinol. He was known to have mild left ventricular dysfunction with a previous transthoracic echocardiogram showing an ejection fraction of 45%. The patient has been on long-term statin therapy, but 3 weeks prior to presentation, atorvastatin 40 mg had been changed to rosuvastatin 20 mg and symptoms had begun at that time.

Cardiovascular examination revealed a regular heart rate of 80 beats per minute, blood pressure of 135/70 mm Hg, and no clinical signs of left or right heart failure. Electrocardiogram (ECG) showed inferior Q waves, which were preexisting. Musculoskeletal examination demonstrated difficulty standing from a chair and proximal muscle weakness of the shoulder girdle and neck (4/5 power in all proximal muscle groups, with preserved distal power).

Cardiac troponin T (cTnT) were 889 ng/L on admission, and 4 hours later, 808 ng/L (<14 ng/L). Urgent transthoracic echocardiography demonstrated normal left ventricular size with mild segmental left ventricular dysfunction (inferior septal, posterior and inferior akinesis, mid-posterior hypokinesis) consistent with previous inferior myocardial infarction, which was present on prior echocardiograph. A cTnT level 12 hours post admission was relatively stable, reaching 953 ng/L in the absence of any further chest pain, and no arrhythmias were detected on telemetry.