Lyme borreliosis is the most common tick-borne disease in the United States. It is caused by spirochetes of the Borrelia burgdorferi species complex. Lyme disease has a myriad of incident symptoms, which can involve the skin as well as the musculoskeletal, neurologic, and cardiovascular systems. Cardiac manifestations usually involve the conduction system, but it may involve the endocardium, myocardium, or pericardium. We report a case where Lyme disease initially presented with chest pain and ST elevations in the inferolateral leads suggestive of an acute coronary syndrome. Patient had myocardial involvement on magnetic resonance imaging. Twenty-eight days later in follow-up, he had atrioventricular conduction delay. Enzyme-linked immunoassay and Western blot were positive for Lyme disease (IgM and IgG). Signs and symptoms resolved after therapy with doxycycline.