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May 9, 2026JACC Case Reports0 citationsOpen Access

Anti-HMGCR Myopathy During NSTEMI Evaluation

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KQKhaleel QuasemMAMICHELLE CARRASQUEL ALVAREZHMHaley Maser

Key Points

  • To evaluate the diagnostic and treatment challenges presented by anti-HMGCR myopathy during NSTEMI evaluation.
  • Clinical case report of a 69-year-old man with progressive proximal weakness and elevated high-sensitivity troponin T.
  • Coronary angiography and myopathy evaluation including high creatine kinase levels and MRI of the thigh.
  • Treatment involved discontinuation of statins and initiation of immunotherapy including methylprednisolone and intravenous immunoglobulin.
  • Patient presented with high creatine kinase of 4,356 U/L, confirmed as anti-HMGCR myopathy with a positive antibody test.
  • Urgent revascularization was complicated by the need for rapid immunosuppression due to diagnosed myopathy.
  • Highlighting the tension between cardiac intervention and the contraindication of statins for myopathy management.

Abstract

BACKGROUND: Anti-3-hydroxy-3-methylglutaryl coenzyme A reductase immune-mediated necrotizing myopathy causes progressive proximal weakness with marked creatine kinase elevation that persists after statin cessation. High-sensitivity troponin T may be elevated in inflammatory myopathies independent of myocardial ischemia, complicating acute coronary syndrome evaluation. CASE SUMMARY: A 69-year-old man presented after a fall with progressive proximal weakness. Rising high-sensitivity troponin T levels prompted non-ST-segment elevation myocardial infarction work-up; angiography revealed severe multivessel coronary artery disease including left main involvement. Concurrent creatine kinase of 4,356 U/L and transaminitis led to myopathy evaluation. Anti-3-hydroxy-3-methylglutaryl coenzyme A reductase antibody was strongly positive (459), and thigh magnetic resonance imaging confirmed diffuse myositis. Statins were discontinued; immunotherapy was escalated to pulse methylprednisolone, intravenous immunoglobulin, and methotrexate. DISCUSSION: This case highlights a management collision: urgent coronary revascularization planning vs absolute statin contraindication requiring rapid immunosuppression for immune-mediated necrotizing myopathy.

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Cite This Study

Quasem et al. (2026) studied this question.

synapsesocial.com/papers/69fecfcdb9154b0b82876d13https://doi.org/10.1016/j.jaccas.2026.108042
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Also Consider

Synapse has enriched 5 closely related papers on similar clinical questions. Consider them for comparative context:

  1. 1Anti-3-Hydroxy-3-Methylglutaryl-Coenzyme A (HMG-CoA) Reductase Negative Statin-Induced Necrotizing Myopathy: A Challenging Case2026
  2. 2Statin-Induced Immune-Mediated Necrotizing Myopathy: An Increasingly Recognized Inflammatory Myopathy2020 · 15 citations
  3. 3Anti-HMGCR antibody-associated necrotising myopathy and its association with statin use2018 · 5 citations
  4. 4Chronic Anti-HMG-CoA Reductase Positive Necrotizing Myositis With Remote Exposure to Statins2023 · 4 citations
  5. 5Immune-Mediated Necrotizing Myopathy With Anti-3-Hydroxy-3-Methylglutaryl-CoA Reductase (HMGCR) Antibodies Following Viral Infection and Without Association With Statin Use: A Case Report2024