Primary Aldosteronism Management

Etiology and Diagnosis

• The majority of primary aldosteronism cases (approximately 50%) are due to bilateral adrenal hyperplasia and require medical rather than surgical management, according to the American College of Cardiology 1
• The primary screening test for primary aldosteronism is the plasma aldosterone:renin activity ratio (ARR) with a cutoff value >30 and plasma aldosterone ≥10 ng/dL, ensuring unrestricted salt intake and normal serum potassium, and withdrawing mineralocorticoid receptor antagonists for ≥4 weeks before testing, as recommended by the American College of Cardiology and the American Heart Association 1, 2, 3, 4
• Patients with resistant hypertension, hypokalemia, incidentally discovered adrenal mass, family history of early-onset hypertension, or stroke at a young age (<40 years) should be screened for primary aldosteronism, according to the American College of Cardiology and the American Heart Association 1, 2
• Confirmatory testing for primary aldosteronism includes either intravenous saline suppression test or oral salt-loading test, as recommended by the American College of Cardiology and the American Heart Association 1, 2
• Adrenal vein sampling (AVS) is recommended for patients with confirmed primary aldosteronism to determine if aldosterone production is unilateral or bilateral, with some institutions excluding AVS in patients younger than 40 years when imaging shows only one affected gland, as bilateral hyperplasia is rare in this population, according to the National Comprehensive Cancer Network 5

Treatment

• For unilateral primary aldosteronism, laparoscopic adrenalectomy is the first-line treatment, improving blood pressure in virtually 100% of patients and completely curing hypertension in approximately 50% of patients, as recommended by the American College of Cardiology and the Endocrine Society 3, 2, 1, 6, 4
• For bilateral primary aldosteronism, mineralocorticoid receptor antagonists, such as spironolactone or eplerenone, are the first-line treatment, with a starting dose of 12.5-25 mg daily and titration up to 100 mg daily as needed, as recommended by the American College of Cardiology and the American Heart Association 1, 5, 3, 2, 6, 7
• The following table summarizes the key aspects of hyperaldosteronism and pheochromocytoma management:

Monitoring and Follow-up

• Initial monitoring after starting treatment for primary aldosteronism includes checking serum potassium and renal function within 1-2 weeks, and monitoring potassium at 3 days and 1 week after initiating therapy, then monthly for the first 3 months, as recommended by the American College of Cardiology and the American Heart Association 1, 7
• Long-term monitoring of primary aldosteronism treatment involves regular assessment of blood pressure control, periodic measurement of serum potassium and renal function, and watching for side effects such as gynecomastia, sexual dysfunction, and menstrual irregularities, according to the American College of Cardiology and the European Heart Journal 1, 6, 7
• Common side effects of MRAs include gynecomastia and breast tenderness in men, menstrual irregularities in women, sexual dysfunction, and hyperkalemia, especially in patients with renal impairment, as indicated by the European Heart Journal guidelines 6
• Strategies to minimize side effects include using the lowest effective dose, considering eplerenone for patients experiencing sexual side effects, and regular monitoring of potassium levels, especially when combined with ACE inhibitors 1
• Vascular remodeling from delayed diagnosis may result in residual hypertension even after treatment, highlighting the importance of early diagnosis and treatment, as stated by the European Heart Journal 6
• Newer non-steroidal MRAs (finerenone, exarenone) and aldosterone synthase inhibitor (baxdrostat) are being tested for primary aldosteronism, as reported by the European Heart Journal 6