Treatment of Primary Aldosteronism

Primary aldosteronism (PA) is a common cause of hypertension, characterized by renin-independent aldosterone production that drives inappropriate mineralocorticoid receptor activation, sodium retention, volume expansion, and potassium wasting, ultimately resulting in hypertension and adverse cardiorenal outcomes. Management of PA involves therapies that target these pathophysiologic mechanisms to restore homeostasis and reduce risk, which is usually tailored based on patient preference and whether PA is lateralizing or nonlateralizing. For patients with lateralizing PA, surgical adrenalectomy, and to a lesser extent, minimally invasive adrenal or adrenal artery ablation, is highly effective at improving blood pressure control and risk for incident cardiovascular outcomes. However, the vast majority of patients with PA will be treated with medical therapy using steroidal mineralocorticoid receptor antagonists as the cornerstone of therapy, and epithelial sodium channel inhibitors serving as infrequent alternatives. Dietary sodium restriction in PA should be strongly encouraged because it reduces the substrate that fuels PA pathophysiology; dietary sodium restriction can facilitate substantial reductions in blood pressure, especially when combined with mineralocorticoid receptor antagonist therapy. Once initiated, medical therapy should be intensified to achieve 3 objectives in the following order of importance: normalization of blood pressure with the fewest number of antihypertensive agents, normalization of serum potassium when applicable, and increases in renin from baseline as a biomarker of adequate aldosterone blockade.