Primary aldosteronism Diagnosis and management Plasma aldosterone-to-renin ratio Obtain plasma aldosterone-to-renin ratio to identify primary hyperaldosteronism in suspected patients. B Adrenal venous sampling Perform adrenal vein sampling to distinguish between unilateral and bilateral adrenal disease in patients in patients with primary hyperaldosteronism in whom surgery is feasible and desired. B Genetic testing ES Q Does the patient have onset of confirmed primary hyperaldosteronism earlier than 20 years of age? Q Does the patient have a family history of primary hyperaldosteronism or strokes at a young age (<40 years)? Yes to any Consider genetic testing for familial hyperaldosteronism type 1 in patients with confirmed primary hyperaldosteronism and onset of disease at < 20 years of age, and in patients who have a family history of either primary hyperaldosteronism or stroke at a young age. C No to all Mineralocorticoid receptor antagonists Initiate a mineralocorticoid receptor antagonist in patients with primary hyperaldosteronism due to bilateral adrenal disease. B Consider using spironolactone as the primary agent, with eplerenone as an alternative. C Corticosteroids Q In patients with glucocorticoid-remediable aldosteronism Yes Administer the lowest effective dose of corticosteroids required to lower ACTH and thus normalize BP and potassium levels as first-line treatment in patients with corticosteroid- remediable aldosteronism. B No Indications for adrenalectomy ES Q Does the patient have unilateral primary aldosteronism? Yes Perform ipsilateral laparoscopic adrenalectomy for patients with documented unilateral primary hyperaldosteronism, such as aldosterone-producing adenoma or unilateral adrenal hyperplasia. B No Administer medical therapy, including a mineralocorticoid antagonist, in patients who are unable or unwilling to undergo surgery. B