Suspected Acute Myocarditis in Wolff Parkinson White Syndrome Presenting with Supraventricular Tachycardia and ST Elevation: A Case Report

Abstrak

Background: Myocarditis defined as inflammation of myocardium in response to acute injury. It can cause general and unclear symptoms. On ECG, it may show ST-segment elevation, which often mimicking ACS. Meanwhile, Wolff Parkinson White syndrome is a pre-excitation cardiac condition that is characterized by an accessory conduction pathway that predisposes individuals to tachyarrhythmias, including supraventricular tachycardia. When both conditions co-exist, diagnosis and management become particularly challenging. Case Illustration: A 20-year-old male was admitted to our hospital with palpitations and diaphoresis 8 hours prior to admission, after playing soccer a night before, accompanied with shortness of breath and crushing chest pain. History of recent viral infections were denied. His initial BP was 100/70 mmHg and HR was 200 beats per minute, with normal physical examination. Admission ECG showed AVRT orthodromic. After vagal maneuver, ECG converted to sinus rhythm with ST elevation on inferior leads and suggesting WPW syndrome, troponin level was elevated. Coronary angiography revealed normal coronary arteries except for myocardial bridging in LAD.  CRP and ASTO titers were elevated. Cardiac MR and endomyocardial biopsy were not done yet. This patient then diagnosed with WPW syndrome and suspected myocarditis. Discussion: In WPW patients, the conduction of electrical pulses is no longer limited to the AV pathway due to the presence of accessory pathway, Bundle of Kent, that has considerable potential to cause supraventricular arrhythmias, which the important route is the AVRT route. In this case, myocarditis is thought to be the cause. Myocarditis can trigger arrhythmias due to various factors, including alteration of cardiac structural, vascular involvement, and changes in membrane potential triggered by inflammation. Summary: This case report highlights that myocarditis can act both as a substrate and a trigger for SVT in patients with WPW syndrome. When SVT occurs in WPW patients, we should consider myocarditis as the underlying cause. Early recognition could guide to appropriate management and prevent potential complications associated with both arrhythmia and myocardial inflammation.