BackgroundPrimary aldosteronism (PA) is a common yet underdiagnosed cause of secondary hypertension, particularly in young patients presenting with severe disease.Case SummaryA 31-year-old woman presented with malignant hypertension (264/144 mm Hg), severe hypokalemia (K+ level 2.60 mmol/L), and acute pulmonary edema. Her initial work-up during nicardipine and furosemide infusion showed a normal aldosterone-to-renin ratio (ARR), leading to misdiagnosis as essential hypertension. Over a 3-year follow-up, she developed refractory hypertension during pregnancy and preeclampsia. She was readmitted with torsades de pointes triggered by severe hypokalemia (K+ level 1.90 mmol/L). Repeat testing revealed a markedly elevated ARR (667.26). Adrenal venous sampling confirmed right-sided PA. Right adrenalectomy confirmed a cortical adenoma, with subsequent normalization of blood pressure and potassium levels.DiscussionThis case report highlights the interference of common medications in PA diagnosis, delineates the complete pathophysiological cascade from aldosterone excess to life-threatening arrhythmia, and reveals the dynamic nature of PA-associated adrenal nodules.Take-Home MessagesClinicians must be vigilant about the confounding effects of common antihypertensive agents on ARR interpretation and should consider adrenal imaging as part of the dynamic management of PA. Adrenal venous sampling remains paramount for surgical planning.

BackgroundBilateral coronary microfistulas with redirection to the left ventricle are extremely rare clinical events. Although most cases are asymptomatic, the severity varies according to the redirection of blood flow, possibly leading to type 2 myocardial infarction.Case SummaryA 79-year-old woman with a medical history of hypertension, type 2 diabetes mellitus, hypothyroidism, and anxiety presented with atypical chest pain. Electrocardiogram revealed sinus rhythm with an electrically inactive area in the inferior wall, and serial troponin measurements indicated myocardial injury. Coronary angiography demonstrated bilateral coronary microfistulas draining into the left ventricle, in the absence of obstructive coronary artery disease. The patient was discharged with atenolol and acetylsalicylic acid and remained stable during follow-up.DiscussionThis case contributes to the growing recognition of coronary microfistulas as a rare but clinically meaningful cause of type 2 myocardial infarction, emphasizing the diagnostic value of coronary angiography and reinforcing the importance of individualized conservative management in such diffuse presentations of fistulas.