Today, I review, link to, and excerpt from The Curbsiders‘ “#515 Primary Aldosteronism, A Deep Dive: Easy on the Salt!”*
*Ahmad M, Vaidya A, Williams PN, Watto MF. “#515: Easy on the Salt! A Deep Dive on Primary Aldosteronism”. The Curbsiders Internal Medicine Podcast. thecurbsiders.com/category/curbsiders-podcast February 23, 2026.
All that follows is from the above resource.
Transcript available via YouTube
Helping you diagnose a common cause of hypertension!
Hypertension is a growing disease globally, affecting millions of individuals and increasing the risk of heart disease and stroke. Along with the expert help of Dr. Vaidya (Brigham and Women’s Hospital), we help reimagine the approach of clinicians in terms of hypertension and help them navigate common diagnostic dilemmas! @AnandVaidya17 (Bluesky) @AnandVaidya17 (X)
Claim CME for this episode at curbsiders.vcuhealth.org!
Show Segments
- Introduction and Personal Interests
- Advice and Wisdom in Medicine
- Case 1
- Defining Primary Aldosteronism
- Screening for Primary Aldosteronism
- How common is Primary Aldosteronism
- Challenges in Diagnosis and Testing
- Medication Management and Testing Protocols
- Managing indeterminate cases
- Aldosterone Suppression Testing and its role
- Discussing treatment options with patients
- Case 2
- Considering genetic causes of Primary Aldosteronism
- The need for AVS for lateralization
- Upcoming imaging modalities for Primary Aldosteronism
- Case 3
- Medical Management of Primary Aldosteronism
- Future Directions in Treatment
Primary Aldosteronism Pearls
- Primary aldosteronism is a common cause of hypertension and screening should be considered in all hypertensive patients
- Screening includes checking an aldosterone level, a plasma renin activity or direct renin concentration, an aldosterone renin ratio, along with a potassium level
- Blood pressure medications do not need to be held to screen for PA however you should know how these medicines can affect lab results
- If PA is diagnosed treatment should be guided by whether the patient is interested in surgical management of PA or medical management
- If surgical management is pursued a CT of the abdomen and pelvis without contrast is useful to look for an adenoma and also provides information for an interventional radiologist if adrenal venous sampling is performed
- Just because a person does not have an adenoma does not mean they do not have lateralizing PA so AVS should always be considered in those who wish for surgical management of disease
- When treating individuals with MRA therapy the main goals are normalizing blood pressure, stopping the need for potassium supplements, and increasing renin to a level that is above the baseline for the patient.
Primary Aldosteronism Show Notes
What is primary aldosteronism
Definition
Primary aldosteronism (PA) is a pathologic, non suppressible form of aldosterone excess which is independent of renin and angiotensin II (Vaidya et al. 2022). Primary aldosteronism is not a binary disease but rather exists on a spectrum with some patients having mild disease while others have more severe forms of disease. The etiology of disease is typically due to somatic mutations which can increase in number with time (Vaidya et al. 2022).
Prevalence
Previously, PA was thought to be a rare cause of hypertension, however, growing evidence suggests that it is much more common than previously thought (Rossi et al. 2024, Vaidya et al. 2022). Some studies estimate the prevalence to be 10-25% of all patients with hypertension (Rossi et al. 2024, Vaidya et al. 2022). Despite these high estimated rates of PA, the screening rates are still abysmally low. It is estimated that less than 1% of patients with PA are actually diagnosed (Vaidya et al. 2022). Factors that contribute to these low rates include decreased awareness regarding its prevalence, assuming that patients with PA often have hypokalemia and refractory hypertension, and using high aldosterone cutoffs to diagnose PA (Rossi et al. 2024, Vaidya et al. 2022).
Why is recognizing PA important
Primary hyperaldosteronism has been linked to multiple comorbidities including left ventricular hypertrophy, diastolic dysfunction, chronic kidney disease, stroke, coronary artery disease, type 2 diabetes, and atrial fibrillation (Dogra et al. 2023, Rossi et al. 2024, Vaidya et al. 2022). This increased risk appears to be independent of just hypertension, as studies have shown people with PA are at higher cardiovascular risk as compared to patients with hypertension in the absence of PA (Dogra et al. 2023, Rossi et al. 2024, Vaidya et al. 2022). The pathophysiology behind these risks is thought to be oxidative damage caused by aldosterone, leading to inflammation, fibrosis and vascular damage (Rossi et al. 2024, Vaidya et al. 2022).
Diagnosis of PA
Who to screen
The 2025 Endocrine Society guidelines now suggest screening ALL patients with hypertension at least once for PA, whereas prior Endocrine Society guidelines had various screening criteria that highlighted multiple groups of patients that would benefit from PA screening (Adler et al. 2025). This guidance comes from the increasing number of studies highlighting how prevalent the condition is in hypertensive patients and the fact that screening rates are extremely low. These international guidelines however do suggest screening tests should be sent based on local expertise and experience, resources and healthcare system capacity (Adler et al. 2025). As Dr. Vaidya points out in the podcast however, even if availability of adrenal venous sampling (AVS) or adrenalectomy is low, mineralocorticoid receptor antagonist (MRA) therapy has been shown to be effective in these patients and therefore should not prohibit screening for PA.
How to screen
Screening involves measurement of the aldosterone level, a plasma renin activity (PRA) or direct renin concentration (DRC), and calculation of the aldosterone renin ratio (ARR) (Adler et al. 2025). A potassium level should also be sent at the same time as these labs, as hypokalemia can lower aldosterone levels and give a false negative test. Per the guidelines, testing should take place first thing in the morning fasting, however per Dr. Vaidya, the most practical approach is to have them get blood work whenever they can. Washout of blood pressure medications is not required prior to testing (Adler et al. 2025, Dogra et al. 2023); Dr. Vaidya does not stop medications prior, and suggests only considering washout after initial testing negative and high clinical suspicion.
A positive screening test is an aldosterone concentration greater than or equal to 7.5 ng/dL via LC-MS and 10 ng/dL via immunoassay in the setting of a PRA of less than of 1 ng/ml/h or a DRC of less than or equal to 8.2 mU/L (Adler et al. 2025). Per guidelines, the ARR should be greater than 20 if aldosterone via immunoassay/PRA is used or greater than 15 if aldosterone via LC-MS/PRA is used (Adler et al. 2025). Of note, just because screening was performed and was negative once does not mean it should not be repeated. A study by Yozamp at al. demonstrated there is intraindividual variation in aldosterone and renin concentrations and ratios on a day-to-day basis, and if you have a high suspicion you should retest (Yozamp et al. 2020).
