Feature Article

Primary aldosteronism – efficiently making a commonly missed diagnosis

Feature Article

Primary aldosteronism – efficiently making a commonly missed diagnosis

Elisabeth Ng, Jun Yang

Figures

© ALEX_KOCK/shutterstock.com
© ALEX_KOCK/shutterstock.com

Abstract

Primary aldosteronism is a highly prevalent but underdiagnosed cause of hypertension despite targeted therapies being readily available. Increased awareness of this condition will improve rates of diagnosis and outcomes for affected individuals.

Key Points

  • Primary aldosteronism (PA), characterised by autonomous aldosterone secretion from the adrenal glands, is a common but underdiagnosed form of hypertension.
  • PA causes an increased risk of heart disease, stroke and atrial fibrillation compared with blood pressure-matched essential hypertension.
  • The clinical features of PA can vary from asymptomatic hypertension to resistant hypertension, with hypokalaemia being present in a minority of patients.
  • Screening for PA is performed with the plasma aldosterone concentration (within or above normal range), renin level (direct renin concentration or plasma renin activity that is low or suppressed) and the calculated aldosterone-to-renin ratio (raised above a laboratory-specific threshold).
  • A positive screening test is followed by confirmatory testing, and then subtyping with adrenal imaging and adrenal vein sampling to determine if the aldosterone excess is from one adrenal gland (unilateral PA) or both (bilateral PA).
  • Unilateral PA can be cured with laparoscopic adrenalectomy, whereas bilateral PA can be treated effectively with mineralocorticoid receptor antagonists such as spironolactone.