In addition to today’s resource, please review Primary Aldosteronism: An Endocrine Society Clinical Practice Guideline [PubMed Abstract] [Full-Text HTML] [Full-Text PDF]. The Journal of Clinical Endocrinology & Metabolism, Volume 110, Issue 9, September 2025, Pages 2453–2495, https://doi.org/10.1210/clinem/dgaf284
Published: 14 July 2025
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.
Audio
Video
#515 Primary Aldosteronism, A Deep Dive: Easy on the Salt!
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)
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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
Disclosures
Dr. Vaidya has disclosed the following:
Financial Relationships: Astra Zeneca-Consulting Fee and Corcept-Consulting Fee, relationships have not ended.
The Curbsiders report no relevant financial disclosures.
The Curbsiders are partnering with VCU Health Continuing Education to offer continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit.
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.
