42-year-old male presenting with chest pain.

History, current illness and physical examination
Personal history: Rheumatic fever in childhood. IQ: Osteosynthesis in EID. Seaman by profession.
No usual treatment.
AF: Brother died at 35 years of age due to AMI.
Present illness: 42-year-old male presenting with epigastric and oppressive precordial pain associated with vegetative cortex lasting 3 hours. The previous month he had presented with sinusitis treated with antibiotics. In view of his clinical presentation, he went to his health centre, where an ECG was performed.

Physical examination: Patient conscious and oriented. Eupneic. BP 130/90 mmHg, HR 73 bpm. No jugular ingurgitation. Cardiac auscultation: rhythmic, no murmurs. Pulmonary auscultation: preserved vesicular murmur. Abdomen: no pathological findings. Lower extremities: no oedema or signs of DVT. Distal pulses present and symmetrical.

Complementary tests
- ECG: regular wide QRS tachycardia, 220 bpm, right bundle branch block morphology and superior axis.
- Catheterisation: Coronary angiography: No angiographically significant coronary lesions. Left ventriculography: Severe systolic dysfunction.
- Laboratory tests: Peak TnT ultrasensitive peak of 267 ng/L.
- Echocardiogram 3 days after admission: non-dilated left ventricle with slightly depressed global systolic function and severe hypokinesia of the basal and middle segments of the lateral, inferior and posterior face, without significant valvulopathies.
- Cardiac MRI: Hypokinesia of mid-apical segments of the lateral face and akinesia of the basal segment of the lateral face. In the late myocardial enhancement series, subepicardial base uptake is demonstrated, respecting the subendocardium, affecting lateral and inferior segments at basal and mid level. Mild pericardial effusion. Findings compatible with acute myocarditis.
- Electrophysiological study: Using a digital anatomical reconstruction system, two areas of subventricular eschar are evident. Ventricular tachycardias of the same morphology as that presented by the patient on admission were induced on several occasions, but with poor clinical tolerance that prevented their mapping and forced them to be terminated with over-stimulation. Finally, it was decided to perform several radiofrequency applications around the bedsores in sinus rhythm.

Clinical evolution
In view of the patient's clinical and ECG findings, the Emergency Department was notified, who prescribed sedation and performed synchronised ECV at 100J, reverting to sinus rhythm, and the patient was subsequently transferred to the Intensive Care Unit of his referral hospital. At the centre, coronary angiography and serial analyses were performed, with the aforementioned results. Once clinical stability was achieved, the patient was discharged to the hospital ward and treatment was started with ACE inhibitors and beta-blockers with good clinical tolerance. An echocardiogram was performed, which showed an improvement in left ventricular function compared to the ventriculography performed on admission, and cardiac MRI, with findings compatible with acute myocarditis. Following an electrophysiological study, an ICD was implanted without incident, and the patient was discharged home with ACE inhibitors and beta-blockers.

Diagnosis
Sustained monomorphic ventricular tachycardia reverted to sinus rhythm with CVE in the context of probable acute myocarditis.
