Intraoperative Hypertensive Crisis Unveiling Normotensive Primary Aldosteronism: Mechanistic Insights, Clinical Implications, and Translational Perspectives in Cardiovascular Medicine

Abstract Background: Normotensive primary aldosteronism (PA) is an underrecognized phenotype of aldosterone excess that may remain clinically silent until provoked by physiological stressors. Intraoperative hypertensive crises (IHCs) represent acute, severe elevations in blood pressure (BP) triggered by surgical stress, catecholamine surge, and anesthetic modulation. The occurrence of IHC in patients without preoperative hypertension may unmask latent endocrine contributors, particularly PA, with significant implications for perioperative management and long-term cardiovascular risk. Objectives: We aimed to (1) characterize the clinical and biochemical features of normotensive PA revealed by intraoperative hypertensive crises, (2) explore underlying pathophysiological mechanisms linking aldosterone excess to stress-induced BP dysregulation, and (3) discuss translational implications for cardiovascular medicine, including diagnostic strategies and therapeutic interventions. Methods: A series of patients experiencing severe intraoperative BP elevations (>180/110 mmHg) without documented preoperative hypertension were retrospectively identified. Diagnostic workup postoperatively included measurement of plasma aldosterone concentration (PAC), plasma renin activity (PRA), aldosterone-to-renin ratio (ARR), confirmatory suppression testing, and adrenal imaging. Mechanistic pathways were reviewed, integrating evidence from cellular models of mineralocorticoid receptor activation, autonomic regulation, and vascular responsiveness under acute stress conditions. Results: Among patients with IHC and previously normal office BP, a subset demonstrated elevated ARR and abnormal confirmatory suppression testing consistent with PA. Adrenal imaging revealed unilateral adenomas in several cases, with histopathological confirmation post-adrenalectomy. Mechanistic analyses implicated enhanced vascular sensitivity to catecholamines, dysregulated autonomic balance, and aldosterone-driven endothelial dysfunction as contributors to acute BP escalation under stress. Patients receiving targeted mineralocorticoid receptor antagonists preoperatively exhibited attenuated BP responses during subsequent procedures. Conclusions: Intraoperative hypertensive crises in ostensibly normotensive individuals may serve as a clinical harbinger of occult primary aldosteronism. Recognizing this association is critical for timely diagnosis, risk stratification, and tailored management to mitigate perioperative cardiovascular complications. Prospective studies are warranted to refine screening algorithms and evaluate the impact of early intervention with mineralocorticoid receptor blockade on cardiovascular outcomes.