On July 7, 2010, a 74-year-old man came to our hospital, complaining that he had a nagging pain in his chest that started the preceding day. After performing electrocardiography, blood tests and electrocardiography, we diagnosed the case as acute myocardial infarction. At first, it was thought that blood flow could be restored in due course of time, antiplatelet and anticoagulant agents were used. Intracardiac catheterization was not included in our initial treatment plan. Three days after the initiation of the treatment, the patient had pain in his left inguinocrural region. Computed tomography and magnetic resonance imaging reveled hematoma in his left iliopsoas muscle. We stopped administering antiplatelet and anticoagulant agents to him. But anemia progressed from Hb14.1g/dL to 9.8 g/dL, so blood transfusions had to be given. After that, the patient underwent a rest cure. With the passage of time, the pain and swelling of the left iliopsoas muscle went down. Regarding the cardiac condition, however, the pain in the chest did not abate even when he was taking a rest. The antiplatelet therapy was resumed, with one type of agent given at first and then with another type added. Examinations using a coronary CT and a cadiac catheter found 90% stenosis at the proximal left anterior descending coronary artery. So, a bare metal stent was placed in the near-closed artery. Ever since, there has been no recrudescence of chest pain and no recurrence of iliopsoas muscle hematoma. The extravascated blood mass seemed to be dissolved spontaneously.

Adrenal venous sampling (AVS) is the key procedure for lateralization of primary hyperaldosteronism (PA) before surgery. Identification of the adrenal veins using computed tomography (CT) and intraoperative cortisol assay facilitates the success of catheterization. Although administration of adrenocorticotropic hormone (ACTH) has benefits such as improving the success rate, some unilateral cases could be falsely diagnosed as bilateral. Selectivity index of 5 with ACTH stimulation to assess the selectivity of catheterization and lateralization index (LI) >4 with ACTH stimulation for unilateral diagnosis is used in many centers. Co-secretion of cortisol from the tumor potentially affects the lateralization by the LI. Patients aged <35 years with hypokalemia, marked aldosterone excess, and unilateral adrenal nodule on CT have a higher probability of unilateral disease. Patients with normokalemia, mild aldosterone excess, and no adrenal tumor on CT have a higher probability of bilateral disease. Although no methods have 100% specificity for subtype diagnosis that would allow bypassing AVS, prediction of the subtype should be considered when recommending AVS to patients. Methodological standardization and strict indication improve diagnostic quality of AVS. Development of non-invasive imaging and biochemical markers will drive a paradigm shift in the clinical practice of PA.