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TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Myocarditis is becoming a more recognized complication of COVID-19 with a recent uptrend in cases around the world. This mostly affects individuals with comorbid conditions with a mean age of diagnosis of 50.4 years. Despite a recent increase in the number of COVID-19 related myocarditis, only a handful of cases in North America have been identified in younger individuals, especially with findings consistent with STEMI on electrocardiogram. CASE PRESENTATION: A 21-year-old man with no significant past medical history presented with sudden onset sharp, substernal, non-radiating chest pain of 30 minutes duration. He reported no associated fever, shortness of breath, dizziness or lightheadedness. He was diagnosed with COVID-19 infection two weeks prior to presentation. Initial work-up in the ED showed sinus bradycardia with ST elevation of 2mm in the inferior leads along with elevated troponin of 52 ng/L. Chest x-ray was unremarkable. Aspirin, ticagrelor, atorvastatin and bivalirudin was started. Emergent coronary angiography showed mildly impaired left ventricle systolic function with non-occlusive coronary arteries. A cardiac MRI showed hypokinesis of the inferior wall of the left ventricle, consistent with acute myocarditis. An echocardiogram at four weeks follow-up showed mild/moderate LV systolic dysfunction with EF of 45%. Patient was started on carvedilol and captopril, with complete resolution of symptoms reported on subsequent visit. DISCUSSION: COVID-19 related myocarditis has seen recent upward trends;however, little is known about the pathophysiologic mechanisms. Likely possibilities include a combination of direct viral injury as well as cardiac damage secondary to the host's immune response. Diagnosis is based on clinical findings including changes in EKG and cardiac biomarkers with impaired cardiac performance on echocardiography and/or cardiac MRI. EKG is non-sensitive for diagnosis and can present with variable findings including bundle branch block, QT prolongation, bradyarrhythmia with advanced atrioventricular nodal block and ST elevation or depression, which can be confused as acute myocardial infarction. CONCLUSIONS: COVID 19 related myocarditis is becoming increasingly common, however little is known about pathophysiologic mechanism. Troponin, which has been found elevated in most cases of cases of COVID related myocarditis, making it difficult to distinguish from acute coronary syndrome. Moreover, in severe patients, both ACS and acute myocarditis may present together because of procoagulant and inflammatory nature of COVID-19 infection REFERENCE #1: COVID-19 and Myocarditis: What Do We Know So Far?o Ashar Pirzada, MD, MSc, a Ahmed T. Mokhtar, MBBS, FRCPC, a, b,∗ and Andrew D. Moeller, MD, MASc, FRCPCa REFERENCE #2: Recognizing COVID-19–related myocarditis: The possible pathophysiology and proposed guideline for diagnosis and managemento Bhurint Siripanthong, BA(Cantab),∗ Saman Nazarian, MD, PhD, FHRS,† Daniele Muser, MD,† Rajat Deo, MD, MTR,† Pasquale Santangeli, MD, PhD,† Mohammed Y. Khanji, MBBCh, MRCP, PhD,‡§ Leslie T. Cooper, Jr., MD,# and C. Anwar A. Chahal, MBChB, MRCP, PhD†¶‖∗ REFERENCE #3: COVID-19 pandemic and troponin: indirect myocardial injury, myocardial inflammation or myocarditis?o http://orcid.org/0000-0002-5722-0245Massimo Imazio1,2, Karin Klingel3, Ingrid Kindermann4, Antonio Brucato5, Francesco Giuseppe De Rosa6, Yehuda Adler7, Gaetano Maria De Ferrari8 DISCLOSURES: No relevant relationships by Ahsan Alam, source=Web Response No relevant relationships by Dilpat Kumar, source=Web Response