With increasing legalization, marijuana has become the most commonly abused substance in the United States. Together with the introduction of more potent marijuana products over the years, more adverse events are being reported and clinically characterized. Delta-9-tetrahydrocannabinol (THC) is the active psychotropic component of marijuana, which acts mainly on G-protein cannabinoid receptors CB1 and CB2. Multiple isolated cases of arrhythmias associated with marijuana use have been published. In this manuscript we conduct a scoping study of a total of 27 cases of arrhythmia associated with marijuana. Most cases were reported in young males (81%) with a mean age of 28 ± 10.6 years. Atrial fibrillation (26%) and ventricular fibrillation (22%) were the most common arrhythmias reported. Brugada pattern was reported in 19% of the patients. Marijuana associated arrhythmia resulted in a high mortality rate of 11 %. While the exact mechanisms of arrhythmias associated with marijuana are not clear, several hypothesis have been introduced including the effect of marijuana on cardiac ion channels as well as its effects on the central nervous system. In this paper we discuss the possible mechanisms of marijuana induced arrhythmia citing the evidence available to-date.

The clinical presentations of atherosclerotic disease are the result of a constellation of diverse metabolic and immunologic mechanisms ultimately set into motion by the formation of fatty acid streaks and the accompanying inflammatory cell activation, endothelial damage, smooth muscle proliferation, vascular fibrosis, and end-organ infarction and necrosis. At the heart of atherosclerosis are the byproducts of lipid metabolism, lipoproteins containing triglycerides, phospholipids, and cholesterol, and the changes they undergo that eventually lead to macrophage activation, foam cell formation, and other downstream atherosclerotic changes. Understanding the functionality of cholesterol, triglycerides, and lipoproteins in the cascade of atherosclerotic pathways has tremendous implications on current guidelines for the evaluation and targets in the management of dyslipidemia, and serves as the foundation for future investigations into targets of atherosclerotic therapies.

Takotsubo Cardiomyopathy is a syndrome characterized by transient and reversible regional myocardial dysfunction in the absence of obstructive coronary artery disease classically resulting in ventricular apical ballooning. It has a strong female predominance with onset generally in seventh decade of life, with hypothesized pathophysiology related to excess of catecholaminergic stimulation, particularly during episodes of physical or emotional stress. Takotsubo cardiomyopathy has been previously reported during myasthenic crisis, the acute deterioration of myasthenia gravis typically involving respiratory failure that is also associated with physical or emotional stress. We present the case of an atypically young male patient with classical takotsubo cardiomyopathy in the setting of myasthenic crisis after thymectomy initially concerning for ST segment elevation myocardial infarction, and a review of the literature of takotsubo cardiomyopathy in myasthenic crisis.

A 43-year-old male patient with past medical history of diabetes mellitus (DM), end stage renal disease (ESRD) on hemodialysis (HD), congestive heart failure (CHF), obstructive sleep apnea (OSA), and chronic anemia presented with complaints of left thigh pain. A computerized tomogram (CT) of the thigh revealed evidence of edema with no evidence of a focal collection or gas formation noted. The patient's clinical symptoms persisted and he underwent magnetic resonance imaging (MRI) of his thigh which was reported to show small areas of muscle necrosis with fluid collection. These findings in the acute setting concerned necrotizing fasciitis. After careful discussion following a multidisciplinary approach, a decision was made to perform a fasciotomy with tissue debridement. The patient was treated with IV antibiotics and discharged with a vacuum assisted wound drain. The surgical pathology revealed evidence of muscle edema with necrosis. Seven weeks later the patient presented with similar complaints on the other thigh (right thigh). MRI of the thighs revealed worsening edema with features suggestive of myositis and possible muscle infarction. A CT guided biopsy of the right quadriceps muscle revealed fibrotic interstitial connective tissue and no evidence of necrosis. This favored a diagnosis of diabetic muscle infarction. The disease was managed with pain control, strict diabetes management, and aggressive dialysis.

Marijuana abuse is rapidly growing and currently it is the most coimnon drug of abuse in the United States due to increased legalization for recreational and medicinal use. Delta 9-tetrahydrocannibol, the main psychoactive compound in marijuana, acts via the endocannabinoid system to elicit various cardiovascular physiological effects, and has been associated with many adverse cardiovascular effects such as acute coronary syndrome, arrhythmias, and sudden cardiac death that have previously been reported by our group and others. We present a case of a 30-year-old African-American male with no cardiovascular disease (CVD) risk factors with recurrent ST-segment elevation myocardial infarctions (STEMI) whose coronary angiography revealed recurrent 100% occlusion of the left anterior descending artery (LAD) in the setting of marijuana smoking. It was the patient’s third STEMI with 100% occlusion of the LAD with each STEMI secondary to thrombosis of a different region of the LAD. Marijuana use was confirmed by urine toxicology screening at each STEMI presentation. Coronary angiography on multiple occasions was negative for stenosis of other epicardial coronary arteries, and coronary calcimn scoring was zero. Evaluation for other cardiovascular risk factors including family history of premature coronary artery disease, dyslipidemia, diabetes, and hypercoagulable disorders was negative. Further studies are required to elucidate the mechanisms of marijuana-associated coronary thrombosis and myocardial infarction.

Marijuana is the most common drug of abuse in the United States. Marijuana acts on cannabinoid receptors CB1, CB2 and another distinct endothelial receptor. Marijuana is known to cause tachycardia, hypotension and hypertension. Various arrhythmias including atrial fibrillation, atrial flutter, II degree AV block, ventricular fibrillation, ventricular tachycardia, asystole and brugada pattern associated with marijuana use have been reported. We here present an interesting case of Type I Brugada pattern in electrocardiography (ECG) in a 36 year old healthy African American male who presented after smoking four joints. Urine toxicology test proved marijuana use. Acute coronary syndrome was ruled out, coronary angiogram revealed normal coronaries, 2D echocardiogram showed no evidence of structural heart disease. Upon resolution of Brugada pattern in ECG, procainamide challenge performed in electrophysiology laboratory did not induce Brugada pattern. Patient was asked to return to hospital if he developed fever that did not resolve with antipyretics. Further studies are required to to understand the effect of marijuana on cardiac ion channels.

Heart failure–related recurrent hospitalizations are widely recognized as a source of burden to both patients and the health system. Hospital discharges represent a transition of care and can often become a catalyst for readmission. One strategy in reducing this burden is the implementation of dedicated heart failure clinics. We conducted a retrospective review of all patients discharged from an inner city safety-net public hospital with a discharge diagnosis of heart failure. Patients followed in the Heart Clinic (HC) were compared to those with standard follow-up. All included cases were followed for 30 days after discharge to determine whether an all-cause readmission occurred. There were 258 patient discharges with an overall sicker population in the HC cohort. The HC group had a better event-free survival with a 67.1% reduction in readmission (log rank *p < .05). In concluding, a dedicated heart failure clinic reduced 30-day readmissions for patients who were discharged after having an acute exacerbation of heart failure.

Stroke / Cerebrovascular accident (CVA) is a leading cause of morbidity and mortality in the world. Ischemic stroke accounts for 87% of the cases, 14-30% of which is attributed to cardio-embolic stroke. Lambl’s excrescences (LE) were first described in 1856 by a Bohemian physician- VilemDusanLambl and is considered a rare cause of cardioembolic stroke subtype. LE are branched filiform structures with undulating movements, 1×4-10 mm in size that are usually found on aortic and mitral valves. An atheroma from LE or LE fragments per se may embolize to cerebrovascular arterial territory causing stroke. Multiple isolated cases of stroke associated with LE have been reported in the literature. We hereby report a scoping study of the findings associated with such cases. A total of 27 cases were identified after various scientific databases including PubMed and Google scholar were searched with keywords “lambi’s excrescences, stroke, cerebrovascular accidents”. Data from these cases were tabulated and analyzed. The mean age at presentation was 51 ± 14.2 (± SD) years with 55% of patient younger than 55 years of age. 56% of cases were males. Transesophageal echocardiogram was more effective in detecting LE when compared to transthoracic echocardiogram. LE were most often found on aortic valve and LE related stroke was most often noted in middle cerebral artery territory. Recurrent stroke was reported in 30%. Management of these cases was highly variable and likely derived from individual experience as LE management guidelines are largely lacking. Single and dual antiplatelet therapy, anticoagulation and valvularsurgery were among the various management strategies employed. We recommend dual antiplatelet after the first episode of CVA related to LE and an antiplatelet in combination with anticoagulation after the second CVA attributed to LE. Also it is reasonable to offer valve replacement after second CVA related to LE as the reccurence rate of CVA is high. Due to rarity in LE reporting and its management a shared decision making has to be made depending on the clinical status of the patient. The formation of a worldwide registry for LE using standardized reporting criteria for the diagnosis with or without incident stroke, would help establish guidelines for the diagnosis and management of this rare, yet serious disease with increased risk of morbidity and mortality.