Primary aldosteronism: evidence against a second epidemic

Primary aldosteronism is widely held to be the most common cause of identifiable (secondary) hypertension, reported to be present in 6-10% of all hypertensive patients. This belief reflects the widespread use of the aldosterone-to-renin ratio (ARR) as a screening test. Unfortunately, the ARR is often wrong, leading to even more expensive testing that is also often misleading but that may then lead to potentially harmful additional measures. This review provides evidence that referral bias has markedly inflated the estimates of this condition and recommends a much less aggressive approach to the diagnosis of this condition based on more limited testing and the use of mineralocorticoid receptor antagonists in the treatment of most hypertensive patients.