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A major advancement in the field of medicine has been the introduction and usage of direct oral anticoagulants (DOACs) such as dabigatran (Pradaxa), apixaban (Eliquis), and rivaroxaban (Xarelto). DOACs have been increasing in popularity for mainstay anticoagulation pharmacotherapy and are being preferred by physicians over warfarin due to their rapid onset, fewer drug and food interactions, and lack of frequent blood monitoring. DOACs have been indicated in the management of thromboembolic conditions and have been extensively researched in various medical trials and studies before the approval of dabigatran (Pradaxa) in 2010 by the FDA. DOACs, like warfarin, are associated with a risk of bleeding, requiring clearance of the drug from the bloodstream or administration of reversal agents. It is important for physicians to familiarize themselves with the various types of DOACs and their dosages, along with their advantages and disadvantages in comparison to other non-DAOC classes of medications before incorporating them into their patient management plans.

Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV- 2) was declared a pandemic by WHO in March 2020. The causative organism has since undergone a series of mutations. COVID-19 primarily being a respiratory illness causes pre-existing pulmonary diseases to show worse clinical outcomes. About one-third of the world's population is thought to be infected with latent (MTB). Both previous and newly developed tuberculosis (TB) infection are risk factors for COVID-19 and are associated with poor outcomes. T lymphocytes play a pivotal role in defense against MTB and with evidence suggesting depletion of T lymphocytes in COVID-19, it can be postulated that COVID-19 can increase the risk of reactivation of latent TB.  Given that a large population around the globe is infected with latent tuberculosis, it is interesting to study and note cases where the virus leads to the reactivation of latent tuberculosis infection. Herein, we present a 76-year-old Brazilian male recently treated for COVID-19 pneumonia, presenting with new-onset cough and weakness diagnosed with latent MTB reactivation.

There is a paucity of data and minimal literature on outcomes of percutaneous coronary intervention (PCI) among liver cirrhosis patients. Therefore, we conducted a systematic review and meta-analysis to evaluate the clinical outcomes among liver cirrhosis patients post-PCI. We conducted a comprehensive literature search in the PubMed, Embase, Cochrane, and Scopus databases for relevant studies. Effect sizes were pooled using the DerSimonian and Laird random-effects model as an odds ratio (OR) with 95% confidence intervals (CI). A total of 3 studies met the inclusion criteria, providing data from 10,705,976 patients. A total of 28,100 patients were in the PCI + Cirrhosis group and 10,677,876 patients were in the PCI-only group. The mean age of patients with PCI + Cirrhosis and PCI alone was 63.45 and 64.35 years. The most common comorbidity was hypertension among the PCI + Cirrhosis group compared with PCI alone (68.15% vs. 73.6%). Cirrhosis patients post-PCI were had higher rates of in-hospital mortality (OR, 4.78 (95%CI: 3.39–6.75), p < 0.001), GI bleeding (OR, 1.91 (95%CI:1.83–1.99), p < 0.001, I2 = 0%), stroke (OR, 2.48 (95%CI:1.68–3.66), p < 0.001), AKI (OR, 3.66 (95%CI: 2.33–6.02), p < 0.001), and vascular complications (OR, 1.50 (95%CI: 1.13–1.98), p < 0.001) compared with the PCI group without cirrhosis. Patients with cirrhosis are at a high risk for mortality and adverse outcomes post-PCI procedure compared to the PCI-only group of patients.

The eustachian valve (EV) is a vestigial structure found at the junction of the inferior vena cava and the right atrium, a remnant of the embryological sinus venosus that may persist throughout life. Right-sided infective endocarditis of the eustachian valve remains a distinctly rare and under-diagnosed entity.Commonly known risk factors of eustachian valve endocarditis (EVE) are intravenous drug use, in-dwelling intracardiac devices, and central lines, although more recently immunocompromised states, e.g. uncontrolled diabetes mellitus and old age, have been recognized as risk factors for the disease. Although Staphylococcus aureus has been the most commonly implicated organism, cases of infections with gram-negative organisms are emerging.We present a 47-year-old male with uncontrolled type 1 DM who initially presented to the ED with complaints of low back pain and dysuria and was later found to have eustachian valve endocarditis ultimately treated with intravenous antibiotics.

A hypertensive man in his 80s presented to the emergency department with a fall preceded by a ‘funny turn’ and syncope. Examination findings were consistent with fracture of the left neck of femur. Laboratory investigations, including ECG, were normal. He was discharged after total left hip arthroplasty. During outpatient evaluation for syncope and dizziness, his 24-hour Holter examination showed predominantly sinus rhythm with episodes of first-degree atrioventricular block, ventricular ectopy <1%. Transthoracic echocardiogram showed a large, elongated, mobile left atrial mass with no clear attachment, measuring 4.8 cm × 1.6 cm and a dilated left atrium. (figure 1). Transoesophageal echocardiogram revealed a 4.7 cm × 3.5 cm × 2.6 cm multilobulated, gelatinous, mobile left atrial mass attached to the area around the fossa ovalis of the interatrial septum not prolapsing through or obstructing the mitral valve (figure 2, video 1). CT of thorax, abdomen and the pelvis confirmed intracardiac left atrial mass. There were no signs of extracardiac primary malignancy, metastatic disease or lymphadenopathy. Preoperative workup for surgery was carried out. Coronary angiogram revealed severe proximal left anterior descending artery stenosis and diffuse mild disease in the left circumflex and right coronary artery. He was started on secondary prevention for coronary artery disease. He underwent surgery for myxoma resection and coronary artery bypass grafting with left internal mammary artery graft to the left anterior descending artery. Electrical cardioversion was done for postoperative atrial fibrillation. The patient was discharged home following restoration of sinus rhythm. His biopsy report confirmed left atrial myxoma.

Myocarditis is a rare extraintestinal manifestation of inflammatory bowel disease. Myopericarditis-associated inflammatory bowel disease can be a side effect of the medications used to treat inflammatory bowel disease or the disease process. We present a 25-year-old female with history of ulcerative colitis presented with abdominal pain associated with sharp and central chest pain. She was in a flare of ulcerative colitis with bloody diarrhea. She developed shock and was in intensive care unit. Echocardiogram showed reduced ejection fraction and pericardial effusion. Coronary artery disease, sepsis, thyroid disease were ruled out. She was treated with systemic antibiotics, intravenous steroids, and guideline-directed medical therapy for presumed ulerative colitis associated with myopericarditis and had symptomatic improvement. Treatment of IBD-associated myopericarditis includes the standard induction treatment for IBD with steroids and guideline-directed medical therapy for heart failure.Myocarditis is a rare extraintestinal manifestation of inflammatory bowel disease. Myopericarditis-associated inflammatory bowel disease can be a side effect of the medications used to treat inflammatory bowel disease or the disease process. We present a 25-year-old female with history of ulcerative colitis presented with abdominal pain associated with sharp and central chest pain. She was in a flare of ulcerative colitis with bloody diarrhea. She developed shock and was in intensive care unit. Echocardiogram showed reduced ejection fraction and pericardial effusion. Coronary artery disease, sepsis, thyroid disease were ruled out. She was treated with systemic antibiotics, intravenous steroids, and guideline-directed medical therapy for presumed ulerative colitis associated with myopericarditis and had symptomatic improvement. Treatment of IBD-associated myopericarditis includes the standard induction treatment for IBD with steroids and guideline-directed medical therapy for heart failure.

Numerous drugs prolong the QT interval, and drug-induced QT prolongation is a frequently encountered situation in hospital settings. QT prolongation increases the risk of Torsades de Pointes (TdP), which can be life-threatening. A 70-year-old female with a history of atrial flutter post ablation and ischemic heart disease was admitted for shortness of breath and found to be in atrial flutter with variable atrioventricular block. She was treated with intravenous amiodarone, digoxin loading dose, beta-blockers, and diuretics. The patient converted to sinus rhythm but developed QT prolongation and TdP secondary to amiodarone. The drug was discontinued. After ruling out active ischemia, a diagnosis of idiosyncratic amiodarone-induced TdP was made. Although the incidence of TdP due to amiodarone use is rare, idiosyncratic amiodarone-induced TdP can occur secondary to long QT syndrome or polymorphisms. The treatment includes holding the drug, administration of magnesium sulfate, replenishment of all electrolytes, and cardioversion if needed. Although amiodarone is considered a low-risk drug for precipitating TdP, risk factors including older age, female sex, ischemic heart disease, and electrolyte abnormalities are essential considerations. Drug-induced TdP can be life-threatening due to its potential to degenerate into ventricular fibrillation. Prompt recognition, discontinuation of the drug, and empiric administration of magnesium sulfate are essential.

Abstract Background Cardiovascular involvement is frequent in systemic lupus erythematosus (SLE). Valvular abnormalities are increasingly being recognized with the advent of echocardiography. Case summary We present a case of a 46-year-old lady who presented to the emergency department with upper limb ischaemia. On examination, she had poor dentition and a short systolic murmur on auscultation. A blood workup revealed a diagnosis of SLE. Further investigations showed vegetations on the mitral valve. Initially, an infective endocarditis (IE) diagnosis was made, which was treated with antibiotics. High-dose steroids and immunosuppressants were initiated due to her clinical deterioration and biopsy-proven lupus nephritis. She improved clinically before being discharged home. Discussion It can be difficult to distinguish between IE and Libman–Sacks endocarditis (LSE), especially in the setting of risk factors for both. Antibiotics and immunosuppressants might be started simultaneously in these cases. A multidisciplinary team is required to manage challenging cases of culture-negative endocarditis. Procalcitonin may have a role in differentiating bacterial endocarditis and LSE.

Wellens syndrome is usually diagnosed in asymptomatic patients with normal or only slightly elevated cardiac enzymes. There are two different ECG patterns (Type A and Type B) described in the literature. Earlier studies demonstrated that the appearance of the Wellens pattern had a specificity of 89% and a positive predictive value of 86% for severe stenosis of the left anterior descending artery (LAD) hence a timely recognition and therapeutic approach may prevent fatal outcomes in the patients. Here we are presenting a case of a 69-year-old gentleman with chest pain and Type A Wellens Syndrome pattern on ECG who was found to have LAD stenosis.