Clinical management of hyperaldosteronism

Primary aldosteronism, or Conn’s syndrome, is a common cause of secondary hypertension with a prevalence of up to 20% in patients with resistant hypertension. It is characterized by inappropriately high aldosterone production, most commonly from a unilateral adrenal adenoma or bilateral adrenal hyperplasia. Aldosterone synthesis in primary aldosteronism is independent of the renin-angiotensin system and not suppressible by volume expansion. Beyond its effect on raising blood pressure, aldosterone excess also mediates adverse cardiovascular, renal and metabolic consequences via its actions at the mineralocorticoid receptor. Patients with hypertension that has an early onset, is difficult to control or is associated with hypokalemia or cardiac dysfunction should be screened using an aldosterone/renin ratio and subsequently confirmed with fludrocortisone or saline suppression testing. The identification of the subtype of primary aldosteronism using radiological imaging and adrenal vein sampling is also important as unilateral disease is curable by surgery. The early diagnosis and targeted treatment of primary aldosteronism with either surgery or mineralocorticoid receptor antagonists is crucial to prevent end-organ damage mediated by aldosterone excess.