Primary Aldosteronism: Reassessing Underdiagnosis, Overdiagnosis, and Clinical Decision-Making

Primary Aldosteronism (PA) is postulated to represent one of the most prevalent and significant etiologies of secondary hypertension. A majority of investigations have indicated that the incidence of PA has been escalating, particularly within the cohort of normokalemic individuals. PA generally constitutes an adrenal pathology characterized by excessive production of aldosterone, which may occur bilaterally or unilaterally. The evaluation for Primary Aldosteronism (PA) is alarmingly inadequate, frequently postponed until a substantial duration after the identification of hypertension, generally occurring after the onset of significant adverse health outcomes. This situation may, in part, stem from prevalent misconceptions that PA exists solely in conjunction with hypokalemia, adrenal macro-nodules, markedly elevated levels of aldosterone, or severely elevated blood pressure. Despite the effective methods for diagnosing and treating PA, it remains markedly underdiagnosed and undertreated. The screening and diagnosis of Primary Aldosteronism represent a critical advancement for the timely management of the condition; however, it can occasionally pose significant challenges for healthcare professionals. As a screening methodology, the plasma aldosterone concentration to renin ratio continues to serve as a pragmatic and dependable indicator, acknowledging that aldosterone levels are affected by numerous confounding variables, including ethnicity, gender, pharmacological agents, and the timing of measurements. This review aimed to highlight the optimal conditions for measuring plasma aldosterone levels and discuss who should undergo PA screening and when. It also aims to critically reassess clinical outcomes, diagnostic methodologies, and treatment strategies related to Primary Aldosteronism through the presentation of a detailed case report. Furthermore, this review emphasizes the diagnostic methodologies that should be prioritized in clinical practice by elucidating a specific case.