Primary Aldosteronism: Evaluation and Management in the Hypertensive Patient

Primary aldosteronism (PA) is common, underdiagnosed, and associated with excess cardiorenal risk. We review recent changes in screening, diagnosis, treatment, and implementation.

Contemporary guidelines have broadened screening and reduced barriers to aldosterone-to-renin ratio testing through medication-tolerant, assay-aware interpretation. Confirmatory aldosterone suppression testing is increasingly de-emphasized, with selective use or omission in high-probability patients when results are unlikely to change management. Adrenal vein sampling remains standard for most surgical candidates, while molecular imaging is emerging as a noninvasive alternative. Adrenalectomy is preferred for lateralizing disease; mineralocorticoid receptor antagonists remain first-line therapy for bilateral or nonoperative disease, with renin response increasingly used to assess dosing adequacy. Finerenone and aldosterone synthase inhibitors are potential emerging options. PA care is shifting from a rigid multistep workup toward earlier detection and treatment-directed evaluation. Future work should define scalable screening pathways and compare outcomes of emerging diagnostic and therapeutic strategies.