Non-ST elevation myocardial infarction and post-stenting ventricular septal defect in the setting of viral myocarditis

A 58-year-old hypercholesterolemic male presented to the emergency room (ER) with palpitations, fatigue and shortness of breath. He was afebrile with an irregular heart rate (80–90 bpm), BP of 92/70 mmHg, respirations of 20/min, and an otherwise unremarkable physical examination. ECG showed atrial fibrillation (Afib) with mean heart rate of 80–90 bpm, left ventricular hypertrophy (LVH) and non-ischemic appearing ST elevation diffusely (Figure 1A), and he was admitted to the intensive care unit (ICU). Supplemental oxygen and intravenous fluids were given with excellent response. There were no signs or symptoms of infection. Troponin-I was 1,491.30 pg/mL. Transthoracic echo (TTE) showed mild LVH with normal left ventricular (LV) ejection fraction (EF) and segmental left anterior descending (LAD) territory hypokinesis with a normal pericardium. The working diagnosis was recent onset Afib with unstable angina. As an intermediate risk symptomatic patient, he underwent coronary computed tomography angiography (CCTA) (1). Despite controlled Afib, a 64-MDCT scan was diagnostic, and a coronary calcium score was 76 [62nd percentile, i.e., low probability of obstructive coronary artery disease (CAD)].