SHM Converge Scientific Abstract ePoster Gallery-From Reflex to Reflection: Rhabdomyolysis Disguised as Acute Coronary Syndrome

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This case report describes rhabdomyolysis presenting like acute coronary syndrome (ACS) in a 91-year-old man with chest pain, elevated troponin, and acute kidney injury. Because ECG and imaging were nondiagnostic, initial concern was ACS, and conservative management was chosen given the patient’s age and comorbidities. However, additional laboratory findings—markedly elevated AST/ALT and urinalysis showing heme positivity without red blood cells—suggested myoglobinuria. A creatine kinase level of 7,000 U/L confirmed rhabdomyolysis.<br /><br />Medication review revealed chronic atorvastatin use with recently added ranolazine. Since ranolazine inhibits CYP3A, it can increase statin levels and raise the risk of muscle toxicity. In this patient, the drug interaction likely caused skeletal muscle injury. The case emphasizes that troponin elevation can occur in rhabdomyolysis, renal dysfunction, or systemic illness, which may confuse the diagnosis in older patients with multiple comorbidities.<br /><br />The report highlights the importance of integrating clinical context, laboratory patterns, and medication reconciliation to distinguish rhabdomyolysis from true myocardial ischemia. A simple urinalysis clue—heme positive urine without RBCs—was key to identifying myoglobinuria and avoiding unnecessary invasive cardiac procedures.<br /><br />Overall, the case reinforces the hospitalist’s role as a diagnostic integrator and offers a practical clinical pearl: in patients with polypharmacy who present with possible ACS, always consider rhabdomyolysis and review for statin-drug interactions.

Asset Subtitle

Gauri Pikale

Meta Tag

Author List Amit Arora, Gauri Pikale, Harin Shah, Izna Hadi, Joaquim Noguer, Maryna Shayuk

Category Clinical Vignettes

Concept Rhabdomyolysis

Concept Creatine Kinase

Concept Drug-Drug Interaction

Concept Statin

Concept Muscle Toxicity

Distinguished Non-Finalist

Presenter Organization Northwestern Medicine McHenry Hospital/Rosalind Franklin University of Medicine and Science

Presenting Author Gauri Pikale

Track Adult

Keywords

rhabdomyolysis

acute coronary syndrome

troponin elevation

myoglobinuria

statin toxicity

atorvastatin

ranolazine

drug interaction

acute kidney injury

polypharmacy

Rhabdomyolysis

Creatine Kinase

Drug-Drug Interaction

Statin

Muscle Toxicity