Case Presentation: The patient is a 52 year old female with a history of Scleroderma, Raynaud’s, and APLS who presented to the emergency department for new onset chest pressure for 1 day. On physical exam, vital signs were 99 F, 152/99, 109, and 96% on RA and no cardiac murmurs, crackles on lungs, or pitting edema noted. Labs were remarkable for elevated troponin and EKG for sinus tachycardia. Chest Xray demonstrated pulmonary vascular congestion and small right pleural effusion. CT Chest with IV contrast was performed and showed no pulmonary embolism. TTE was remarkable for severe reduced left ventricular systolic function with an EF of 20% and trace pericardial effusion. The patient was admitted for an NSTEMI with new onset heart failure. She was started on lasix and was scheduled for a cardiac catherization procedure, however the patient developed acute kidney injury. The patient was started on captopril to help a potential scleroderma renal crisis. Given worsening renal function, cardiac catherization was not performed and a cardiac MRI was done to determine if her chest pain was not ischemic in nature. Cardiac MRI revealed thickening of left ventricle, suggestive of scleroderma. As the patient’s kidney function continued to worsen and she became more encephalopathic, hemodialysis was started. She had a renal biopsy which demonstrated thrombotic microangiopathy and diffuse proliferative glomerular nephropathy with immune complex deposition. This case concluded with the patient not pursing a cardiac cath, started on IV solumedrol and cellcept, and the the patient becoming dependent on hemodialysis.

Discussion: This case presents an interesting case of a patient who presented with chest pain that was more complicated than expected. Despite elevated troponins, the EKG demonstrated sinus tachycardia, no ST elevations or depressions or T wave inversions. Her chest pain was more atypical in nature as it was present for a day and not substernal in nature. This demonstrates the utility in cardiac MRI, in which a cardiac cath would’ve only worsened this patient’s acute kidney injury. With cardiac MRI it demonstrated that the patient had an non-ischemic cardiomyopathy, indicating that a cardiac cath was not warranted. Also with new onset heart failure with reduced ejection fraction, the patient had to be started on goal directed medical therapy.

Conclusions: NSTEMI could be described as an ischemic event in which a patient experiences chest pain at rest or on exertion with elevated troponin and a normal EKG [1]. Scleroderma is a connective tissue disease that could affect multiple organ systems [2]. In the average patient with risk factors or concerning features, they would pursue a cardiac catherization and provide an intervention. However, given this patient’s persistent scleroderma renal crisis and imaging of the heart less suggestive of ischemic disease, this was not pursued.