A 42-year-old man with a recent flu-like illness presents with dyspnea and chest pain. Echo shows LVEF 30%, global hypokinesia, mildly dilated LV. Troponin I is elevated. CMR demonstrates diffuse mid-myocardial late gadolinium enhancement (LGE) in a non-ischemic pattern. Coronary angiography is normal. What is the diagnosis and immediate management priority?

• A STEMI equivalent — urgent PCI
• B Dilated cardiomyopathy — start GDMT immediately without further evaluation
• C Hypertrophic cardiomyopathy with apical variant
• D Acute myocarditis — supportive care, avoid NSAIDs, competitive athletics restriction ✓

Explanation

Non-ischemic mid-myocardial LGE on CMR following a viral prodrome is the hallmark of acute myocarditis (Lake Louise criteria met). Treatment is supportive with rest, avoidance of NSAIDs (which worsen myocardial injury in viral myocarditis models), ACE inhibitors/beta-blockers if LV dysfunction present, and strict restriction from competitive athletics for 3–6 months (risk of sudden cardiac death). Endomyocardial biopsy is reserved for severe or fulminant presentations not responding to support. Normal coronaries exclude ischemic etiology.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.