Primary aldosteronism (PA), excess aldosterone secretion by the adrenal glands, raises blood pressure and is prevalent in up to 14% of patients with hypertension. Despite this, it is rarely diagnosed. The Endocrine Society recently published guidelines on primary aldosteronism that cover screening, diagnosis, and treatment. Important points from the recommendations include the following:

• Screening: Screen all patients with hypertension for primary aldosteronism by measuring serum/plasma aldosterone concentration and plasma renin (concentration or activity) to determine the aldosterone to renin ratio (ARR)
• Diagnosis: If screening is positive, determine the probability of lateralizing disease, which is excess aldosterone from one adrenal gland. Findings consistent with lateralizing disease include hypokalemia, age less than 35 years, a unilateral adrenal mass, and/or very low renin with high aldosterone. If probability is high, proceed directly to adrenal CT scan and adrenal venous sampling. If probability is intermediate, consider an empiric trial of a mineralocorticoid receptor antagonist (MRA) versus proceeding to aldosterone suppression testing. If probability is low, consider a trial of an MRA.
• Treatment: If disease is lateralizing, offer surgery. Otherwise, treat with an MRA.

There are no controlled trials supporting the cost-effectiveness or benefits of screening all patients with hypertension for primary aldosteronism. Given that 120 million U.S. adults have hypertension, it's unlikely many providers are going to spend their time chasing this diagnosis in every patient. Other issues with screening include: (1) many common medications interfere with testing (e.g., beta blockers, NSAIDs, diuretics, ARBs, ACE inhibitors, SGLT2 inhibitors) and need to be withdrawn before screening, making the process onerous, (2) studies evaluating the accuracy of the ARR for diagnosing primary aldosteronism have found that it performs poorly.

These guidelines are helpful when assessing patients for primary aldosteronism. However, the recommendation to screen all individuals with hypertension is impractical and unlikely to be cost-effective. The American Heart Association recommends a more targeted approach when selecting patients for secondary hypertension screening (see who to evaluate for secondary hypertension).

• Primary aldosteronism recommendations
• Aldosterone in potassium regulation