Patient: Female, 41 Final Diagnosis: Acute ischemic stroke and ST elevation myocardial infarction Symptoms: Chest pain • facial droop Medication: — Clinical Procedure: — Specialty: Cardiology Objective: Rare co-existance of disease or pathology Background: Acute ST-elevation myocardial infarction and acute ischemic stroke are both life-threatening conditions with high risk for morbidity and mortality without timely intervention. This simultaneous event has been reported to be as rare as 0.009%. The treatments of both conditions individually have been well documented in the literature and guidelines, but when presenting concomitantly, it poses a unique therapeutic challenge. Immediate treatment of one condition can delay management or even have deleterious effects on the other condition. Case Report: We present the case of a 41-year-old female with simultaneous acute anterior ST-elevation myocardial infarction and acute left middle cerebral artery ischemic stroke. Due to a low National Institute of Health score she was not a candidate for endovascular treatment and received alteplase per acute ischemic stroke protocol with delayed percutaneous coronary intervention. She was eventually discharged to a long-term acute care facility for continued rehabilitation. Conclusions: The co-existence of ST elevation myocardial infarction and acute ischemic stroke is rare, but when these 2 common conditions present simultaneously, it provides a unique therapeutic challenge. Although infrequent, this challenging scenario deserves more recognition and a discussion among the medical community.

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Patient: Female, 73Final Diagnosis: Drug induced acute hepatitisSymptoms: Abdominal pain • diarrhea • vomitingMedication: —Clinical Procedure: —Specialty: Gastroenterology and HepatologyObjective:Unusual or unexpected effect of treatmentBackground:The use of herbal medications to treat various diseases is on the rise. Cinnamon has been reported to improve glycolated hemoglobin and serum glucose levels. When patients consider the benefit of such substances, they are often not aware of potential adverse effects and drug interactions. Cinnamon, via coumarin, can cause liver toxicity. Therefore, its concomitant use with hepatotoxic drugs should be avoided.Case Report:A 73-year-old woman was seen in the Emergency Department complaining of abdominal pain associated with vomiting and diarrhea after she started taking cinnamon supplements for about 1 week. The patient had been taking statin for coronary artery disease for many months. The laboratory workup and imaging studies confirmed the diagnosis of hepatitis. The detail workup did not reveal any specific cause. Cinnamon and statin were held. A few weeks after discharge, the statin was resumed without any further complications. This led to a diagnosis of cinnamon-statin combination-induced hepatitis.Conclusions:A combination of cinnamon supplement and statin can cause hepatitis, and it should be discouraged.

It is a common medical practice to anticoagulate an asymptomatic left ventricular mural thrombus following an ST-elevation myocardial infarction using a vitamin K antagonist. Novel oral anticoagulants have not been studied extensively in this context, and therefore, no recommendations have been made for their use. A 67-year-old male physician with no significant medical history presented to the cardiology clinic complaining of shortness of breath that had been gradually worsening over a 2-week period and was found to have an anterior wall myocardial infarction with apical left ventricular thrombus that was treated with apixaban. We present a case of rapid resolution of left ventricular thrombus with the use of apixaban for anticoagulation. Although there are no guideline recommendations for this use, there have been case series and case reports that have shown safety and efficacy. Apixaban can be used for rapid resolution of left ventricular thrombus treatment.

Background:Patients who are candidates to receive an Angioseal® (St. Jude Medical) device for arteriotomy closure are allowed to ambulate 20 min after the deployment of the device. More frequently, however, patients are kept on bed rest for several hours following Angioseal® deployment. The purpose of this study was to prospectively assess patients when ambulating 20 min after Angioseal® deployment instead of prolonged best rest of 2-3 h. Methods: Patients undergoing angiography from the common femoral artery approach were included in the study if they received a 6 Fr Angioseal® closure device. Results: Twenty-nine patients were successfully enrolled in the study; 27 (93.1%) patients ambulated at 20 min, 1 (3.45%) patient ambulated at 28 min, and 1 (3.45%) patient ambulated at 27 min due to transport times. There were zero complications with regard to hemorrhage or other groin complications. There is a substantial time difference in ambulation times between the conventional and early ambulation groups. Conclusion: Our study demonstrates that it is probably safe to ambulate patients who undergo diagnostic cardiac catheterization as early as 20 min after deployment of the 6 Fr Angioseal® closure device. ClinicalTrials.gov identifier: NCT03142126