New-onset complete heart block (CHB) occurring in a healthy young female is a relatively rare finding. We report a case of a 33-year-old female who was incidentally found to have CHB after presenting with a left tibial shaft fracture after a fall. Despite a past medical history of epilepsy, the maintenance of a long, seizure-free period coupled with the absence of neuromuscular weakness prompted a thorough investigation, and the etiology of the CHB was ultimately determined to be lacosamide (LCM), the antiseizure medication. The discontinuation of LCM resulted in spontaneous conversion to sinus rhythm, and an outpatient follow-up 4 weeks after discharge revealed no further episodes of falls, heart block, or other symptoms. We believe this is a rare presentation of LCM-induced CHB in an otherwise healthy young female.

Case description: A 68-year-old man with history of prostate cancer, anal and scrotal squamous cell carcinoma presented to the cardiology clinic with dyspnea on exertion with exercise tolerance limited to 2 flights of stairs. Physical examination showed grade 3/6 holosystolic murmur best heard at the left lower sternal edge. A transthoracic echocardiograph (TTE) revealed an ejection fraction of 65%, prominent muscle bound right ventricular outflow tract obstruction (RVOT) consistent with double chambered right ventricle (DCRV), and a Windsock deformity of the membranous interventricular septum through which there was a VSD with left to right shunting. The maximal pressure gradient across the VSD was approximately 116mmHg. The pulmonary artery systolic pressure was 61mmHg; consistent with severe pulmonary artery hypertension. Discussion: DCRV is a rare condition accounting for 0.5 to 2% of congenital heart diseases. It is characterized by abnormal muscle bands that divide the right ventricle into two chambers; a proximal high-pressure and distal low-pressure chamber, leading to progressive right ventricular outflow tract obstruction (RVOT). This condition rarely occurs in isolation and is often ventricular septal defect (VSD), which is seen in up to 90% of DCRV cases. DCRV may go undiagnosed until adulthood. As the degree of RVOT increases, patients present with shortness of breath and decreased exercise tolerance. TTE is an invaluable tool for diagnosing and determining the severity of obstruction through pulsed and continuous wave doppler to measure the gradient across the hypertrophied muscle bundles. Current guidelines recommend surgery in asymptomatic patients with severe right ventricular obstruction with a pressure gradient greater than 40 mmHg between the proximal and distal compartments within the right ventricle. Even though our patient was mildly symptomatic, his significant pressure gradient of 116 mmHg warrants surgical evaluation. Conclusion: DCRV is a rare and often overlooked congenital heart disease. The patient, despite mild symptoms, exhibited classic features of DCRV and associated VSD, highlighting the potential for this condition to persist undiagnosed into late adulthood. The presence of severe pulmonary hypertension further emphasizes the importance of early detection and ongoing management to prevent severe complications such as heart failure and sudden cardiac death.

Among White rheumatoid arthritis (RA) cohorts, heart failure with preserved ejection fraction (HFpEF) is the most prevalent type of heart failure (HF). We aimed to assess the type of HF affecting Black RA patients. 64 patients with RA-HF were compared to age-, sex-, and race-matched RA patients without HF. Left ventricular ejection fraction (LVEF), wall motion abnormalities, left ventricle (LV) mass, and wall thickness were reviewed. 87.3% were Black, 84.4% were women, with a mean age of 69.6 ± 1.38 (± SEM) and BMI (kg/m 2) 29.6 ± 1.07. RA-HF patients had higher rates of hypertension (HTN), chronic kidney disease, and atrial fibrillation. 66.7% had ≥3 cardiovascular risk factors compared to RA patients without HF. 2D-echocardiograms of RA-HF revealed that 62.3% had LVEF ≥50%, 37% had diastolic dysfunction, and 43.1% had wall motion abnormalities. LV mass and relative wall thickness measurements indicated LV eccentric remodeling. The odds ratio for HF was 4.7 (1.5-14.53 CI), p<0.01, among RA-HTN group and 3.5 (1.091-11.7 CI) p<0.01 among smokers. In our predominantly Black RA-HF patients, HFpEF was the most common type of HF. HTN was associated with the highest OR for HF. Eccentric hypertrophic remodeling, a known poor prognostic indicator for cardiovascular events, was found. Further studies are required to confirm our findings.

Chronic kidney disease (CKD) confers worse cardiovascular (CV) outcomes. Patients are known to have increased atherosclerosis and revascularization rates due to prolonged inflammation and presence of CV risk factors. Increased revascularization after percutaneous coronary intervention (PCI) has been established in end stage renal disease patients (ESRD) and we set to evaluate outcomes in CKD patients. We conducted a systematic review and meta analysis on EMBASE, Pubmed, Cochrane, Web of Science databases to analyze studies with PCI outcomes in patients with and without CKD. Target vessel revascularization, target lesion revascularization, target lesion failure were the primary outcomes studied. 29 articles were included comprising 93190 patients. CKD patients were older ( 70.2 vs 62.6 years). The CKD cohort had higher rates of hypertension, diabetes mellitus, hyperlipidemia with 76.2%, 40% and 65% respectively and a higher prevalence of triple vessel disease ( 29.3 % vs 18% ). Median follow was 24 months.17 studies evaluated target vessel revascularization, showing a non significant risk increase in CKD patients with a risk ratio of 1.14 (95% CI 1 – 1.29). 12 studies evaluated target lesion revascularization, showing a cumulative significant increased risk in CKD patients with a risk ratio of 1.16 (95% CI 1.02-1.32), p=0.02. But the risk was non significant in the randomized controlled trial subgroup analysis as shown in figure 1. Although presence of CKD has higher prevalence of triple vessel disease, it does not affect long term revascularization rates in patients undergoing PCI.

Brugada syndrome is an autosomal dominant channelopathy that usually affects healthy young males without apparent structural heart disease. It is associated with a spectrum of variable and dynamic clinical manifestations, high risk of life -threatening ventricular arrhythmias, and sudden cardiac death. Our patient demonstrated transient and dynamic EKG changes of both type 1 (coved) and type 2 (saddleback) ST elevation, suggestive of the Brugada pattern that was associated with physical chest trauma and stressful situations. While common triggers like fever and certain drugs are well -recognized, this case illustrates the potential for physical stress and trauma to unmask or aggravate Brugada syndrome, albeit without definitive evidence for a causal link. Ultimately, this report underscores the importance of considering a broad differential diagnosis, including Brugada syndrome, in patients presenting with unexplained syncope or characteristic EKG changes, even when traditional triggers are absent.

Tuberculous pericarditis, a rare but potentially lethal manifestation of tuberculosis, poses diagnostic and therapeutic challenges in clinical practice. Its nonspecific clinical presentation often mimics other conditions, leading to delayed or missed diagnoses. We report a 25-year-old male with no past medical history, who presented with nonspecific symptoms such as fatigue, weight loss, body aches, and dyspnea. An electrocardiogram showed low voltage QRS complex with electrical alternans, and transthoracic echocardiography (TTE) showed large pericardial effusion with tamponade physiology with right ventricular diastolic collapse, the collapse of the right atrium and the inferior vena cava was dilated with a respiratory variation of less than 50%. The diagnosis of tuberculous pericarditis was made based on clinical presentation, imaging, and laboratory findings, including a positive QuantiFERON-TB gold test and pericardial fluid analysis, despite negative cultures. This case highlights the significance of considering tuberculosis in the differential diagnosis of pericardial effusion and underscores the role of imaging and laboratory investigations in diagnosis. Management of tuberculous pericarditis involves a combination of antituberculous chemotherapy, pericardiocentesis, and corticosteroids. Despite its rarity, tuberculous pericarditis carries a high mortality rate and can present as cardiac tamponade, as illustrated in our case. This underscores the need for high clinical suspicion, especially in high-risk populations, for timely diagnosis and initiation of treatment.

Introduction: While the association between gout and cardiovascular disease (CVD) has been extensively studied, scarce data is available for the Black population. We aimed to assess, in a predominantly Black urban population with gout, the prevalence of traditional CVD risk factors, CV outcomes, and the strength of the association between gout and CVD after adjusting for CVD risk factors. Hypothesis: Black patients with gout have higher CVD rates compared to a matched cohort without gout. Methods: Cross-sectional analysis of data obtained from the EMR of gout patients followed at our primary care clinics. Patients were identified by ICD codes and compared to age, sex and race matched non- gout cohort. Descriptive data was obtained, and logistic regression used to assess the strength of association between gout and CVD, before and after adjustment for CVD risk factors including obesity, DM, HTN, dyslipidemia and smoking. Results: There were 471 patients with gout with a mean age of 63.7 ± 0.5 years (mean ±SEM); 89% were Black, 63% were men, mean BMI was 31.3 ± 0.4 Kg/m 2 . HTN, DM and dyslipidemia were present in 89%, 46% and 52% respectively.Compared to controls, patients with gout had significantly higher rates of angina, arrythmia, CAD/stents, MI, CABG, CVA, and PVD. The odds ratio (OR) for CVD = 4.5 (3.3-6.2) (95% CI), p<0.001 and OR =2.9 (1.9-4.5), p<0.001 before and after adjustment for CVD risk factors respectively. There was a significantly higher mortality rate of 6.2 in gout vs 2.6 in the non- gout cohort, p <0.01. Conclusion: Gout in a predominantly Black population confers three times the CVD risk and overall mortality compared to a race, age and sex-matched cohort.This risk appears greater compared to previously published data in whites (OR 1.25-1.55) (Choi HK et al Circulation 2007;116:894-900). Further research is needed to confirm our findings and to develop interventions to reduce morbidity and mortality among these vulnerable patients.

Obesity is a major public health problem that is associated with serious comorbidities and premature mortality. Cardiovascular disease (CVD) is the major cause of morbidity and mortality associated with obesity. Lifestyle modifications, pharmacological therapy, and weight reduction surgery are the major interventions to date available for obesity management. Bariatric surgery has been increasingly utilized as a therapeutic option for obesity. In this meta-analysis, we aim to assess the effects of bariatric surgery on CVD outcomes and cardiovascular mortality. This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. PubMed, Embase, Cochrane Library, Google Scholar, and Web of Science were searched until 03/01/2022. Our search included three types of bariatric surgery: Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy, and gastric banding (GB). All were searched in conjunction with "coronary artery disease," "ischemic heart disease," "myocardial infarction," "cerebrovascular accident," "stroke," "atrial fibrillation," "heart failure," "arrhythmias," and "mortality." We included 49 studies meeting the study criteria. Bariatric surgery showed a beneficial effect on coronary artery disease (CAD) (hazard ratio (HR) of 0.68 {95% confidence interval (CI): 0.52-0.91}, p = 0.008), myocardial infarction (MI) (HR of 0.53 {95% CI: 0.44-0.64}, p < 0.01) heart failure (HF) (HR of 0.45 {95% CI: 0.37-0.55}, p < 0.01), cerebrovascular accident (CVA) (HR of 0.68 {95% CI: 0.59-0.78}, p < 0.01), and cardiovascular mortality (HR of 0.48 {95% CI: 0.40-0.57}, p < 0.01). The effect on atrial fibrillation (AF) did not reach statistical significance: HR of 0.81 (95% CI: 0.65-1.01), p = 0.07. Our study, that is, an updated meta-analysis, including the three types of procedure, confirms beneficial effects on the major CVD outcomes, including coronary artery disease, myocardial infarction, cerebrovascular accident, and heart failure, and on CVD mortality. This study provides updated insights into the long-term CV effects of bariatric surgery, an increasingly common intervention for obesity.

Background The systemic complications of vitamin C deficiency, otherwise known as scurvy, have been well-documented in history. Few case reports have documented severe cardiopulmonary complications such as right heart failure (RHF) and pulmonary hypertension (PH).Case summary A 25-year-old female presented to the hospital with two weeks of progressive fatigue, dyspnoea, myalgias, and arthralgias. She was admitted for symptomatic anaemia requiring transfusion. Her symptoms persisted and she developed severe PH and RHF, complicated by cardiogenic shock and multiple episodes of cardiac arrest. She was found to have severe vitamin C deficiency secondary to a severely self-restricted diet. After repletion of vitamin C, the patient had complete resolution of RHF and PH.Discussion This case adds to the sparse literature documenting severe cardiopulmonary complications of vitamin C deficiency. We believe that this is the first adult case of scurvy causing RHF and PH leading to cardiogenic shock and episodes of cardiac arrest. There are multiple hypotheses on the pathogenesis of scurvy-associated PH and RHF, including overactivation of hypoxia-inducible transcription factors and deficiency of vitamin C's vasodilatory effect that acts through increased nitric oxide production in endothelial cells. When recognized, early vitamin C repletion may prevent severe cardiopulmonary complications of scurvy.