In patients with CKD undergoing isolated valve surgery, minimally invasive valve surgery is associated with reduced postoperative complications and lower resource use.

Acute coronary syndrome (ACS) refers to a group of clinical conditions caused by myocardial ischemia including unstable angina, non-ST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI). Appropriate and accurate diagnosis has life-saving implications and requires a quick but thorough evaluation of the patient's history, physical examination, electrocardiogram, radiographic studies, and cardiac biomarkers. The management of patients with suspected or confirmed ACS continues to evolve as new evidence from clinical trials is considered and as new technology becomes available to both primary care physicians and cardiologists. Low- and intermediate-risk patients have frequently been managed in a chest pain center or in the emergency department. While stress testing with or without radionuclide imaging is the most common evaluation method, a CT angiogram is sometimes substituted. High-risk patients are often managed with an early invasive strategy involving left heart catheterization with a goal of prompt revascularization of at-risk, viable myocardium. With the increased availability of cardiac catheterization facilities, patients with STEMI are more commonly being managed with primary percutaneous coronary intervention, although thrombolysis is still used where such facilities are not immediately available. This article provides primary care physicians with a concise review of the pathophysiology, clinical evaluation, and management of ACS based on the best available evidence in 2008.

A 77-year-old woman was admitted to hospital with acute coronary syndrome and hypertensive crisis (i.e., a blood pressure of 210/110 mm Hg on admission). We administered acetylsalicylic acid, metoprolol and enoxaparin. One day later, after her blood pressure was stable and we had ruled out myocardial infarction, we performed an adenosine stress test. During the test, the patient became hypotensive and experienced nausea, confusion and abdominal pain.She had a blood pressure of 70/40 mm Hg and a heart rate of 68 beats/min. She had no jugular venous distension. Her lungs were clear and she had a regular heart rhythm without murmurs, gallops or rubs. Her abdomen was tender over the right lower quadrant and she had a palpable 12 × 5 cm mass in this area with a positive Carnett sign (i.e., an increase in abdominal pain when the head and shoulders are lifted off the examination table).The patient's cardiac troponin levels and an electrocardiogram were normal. Her hemoglobin level had dropped from 100 on admission to 71 (normal 129-158) g/L and her platelet count was 306 (normal 150-300) × 10 9 /L. Prothrombin time and international normalized ratio were within normal range. A computed tomography scan of the abdomen showed a right rectus sheath hematoma associated with a pelvic hematoma (Figure 1). We immediately withheld antihypertensive agents and enoxaparin, performed fluid resuscitation and administered three units of packed red blood cells. The patient's hemoglobin level normalized and she recovered uneventfully.Rectus sheath hematoma is a rare but potentially lifethreatening condition. In one series of rectus muscle masses, rectus sheath hematoma was the most common nonneoplastic cause (22%).1 Although the condition appears to be an uncommon complication of anticoagulation, the incidence among patients receiving anticoagulant therapy is unknown. Risk factors for rectus sheath hematoma include advanced age, systemic anticoagulation (present in 69% of hematomas), intra-abdominal injections, strain of the abdominal wall, minor trauma and pregnancy.2 Clinical manifestations include abdominal pain (84%), Fothergill sign (i.e., an abdominal mass that does not cross the midline and remains palpable when the rectus muscles are flexed), a substantial drop in hemoglobin, abdominal wall ecchymosis (present in 21% of hematomas) and a positive Carnett sign.2,3 A positive Carnett sign suggests the origin of the pain is extra-abdominal rather than intra-abdominal. 3 The diagnosis can be confirmed by ultrasound or computed tomography scan of the abdomen.Treatment of rectus sheath hematoma is usually expectant and may include fluid resuscitation, blood transfusions and management of pain. Uncommonly, intravascular embolization or surgery may be needed. Outcomes are usually favourable, although fatal outcomes have been reported. 4 This article has been peer reviewed.Competing interests: None declared.

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