Management of Primary Aldosteronism

Major advances have been made since Jerome Conn first described the meticulous assessment and surgical treatment of a patient with severe primary aldosteronism (PA) more than 60 years ago. Diagnostic criteria, although still imperfect, have been refined; high definition cross-sectional imaging is widely available; adrenal vein sampling (AVS) is practised to a high standard in selected centres; low-morbidity laparoscopic adrenalectomy (replacing open surgery involving rib resection) is now routine; preliminary data are emerging about the utility of radiofrequency ablation of adrenal nodules as an alternative to surgery; and the range of medical therapies, available or in development, is expanding. Despite this, based on current prevalence estimates, it remains the case that under 1% of patients with PA are fully evaluated and treated. Given the evidence that PA is associated with substantial excess cardiometabolic morbidity over and above that conferred by elevated blood pressure alone, this underprovision of clinical care represents a major public health issue. This chapter will describe the current approach to the management of PA (from its initial suspicion, diagnosis, differential diagnosis, treatment, and evaluation of the success of treatment) and highlight areas of particular uncertainty and controversy.